Brian Fonseca

Use of rotational angiography in assessing relationship of the airway to vasculature during cardiac catheterization

We are the first to describe the use of three‐dimensional rotational angiography (3DRA) in creating multiplanar reconstruction (MPR) and volume rendering, in the catheterization suite, of airways at risk for compression by adjacent cardiac structures.

Apparent Aortic Stiffness in Children with Pulmonary Arterial Hypertension

Background— Left ventricular dysfunction, mediated by ventricular interdependence, has been associated with negative outcomes in children with pulmonary arterial hypertension (PAH). Considering the dilation of the pulmonary arteries as a paramount sign of PAH, we hypothesized that the ascending aorta will present signs of apparent stiffness in children with PAH and that this effect may be because of mechanical interaction with the dilated main pulmonary artery (MPA). Methods and Results— Forty-two children with PAH and 26 age- and size-matched controls underwent comprehensive cardiac magnetic resonance evaluation. Assessment of aortic stiffness was evaluated by measuring pulse wave velocity, aortic strain, and distensibility. Children with PAH had significantly increased pulse wave velocity in the ascending aorta (3.4 versus 2.3 m/s for PAH and controls, respectively; P=0.001) and reduced aortic strain (23% versus 29%; P<0.0001) and distensibility (0.47 versus 0.64%/mm Hg; P=0.02). Indexed MPA diameter correlated with pulse wave velocity (P=0.04) and with aortic strain (P=0.02). The ratio of MPA to aortic size correlated with pulse wave velocity (P=0.0098), strain (P=0.0099), and distensibility (P=0.015). Furthermore, aortic relative area change was associated with left ventricular ejection fraction (P=0.045) and ventricular–vascular coupling ratio (P=0.042). Conclusions— Pediatric PAH patients have increased apparent ascending aortic stiffness, which was strongly associated with the degree of MPA distension. We speculate that distension of the MPA may play a major role in limiting full aortic expansion during systole, which modulates left ventricular performance and impacts systemic hemodynamics in pediatric PAH.

Perioperative Imaging in Hypoplastic Left Heart Syndrome

Hypoplastic left heart syndrome is a constellation of left-sided congenital heart defects that result in variable hypoplasia of the left ventricle, left ventricular outflow tract, and aorta. Perioperative imaging with echocardiography, cardiac magnetic resonance imaging, and cardiac catheterization is vital for diagnosis, surgical planning, prognosis, and postoperative management.

Right Ventricular Longitudinal Strain Is Depressed in a Bovine Model of Pulmonary Hypertension.

BACKGROUND:Pulmonary hypertension and resulting right ventricular (RV) dysfunction are associated with significant perioperative morbidity and mortality. Although echocardiography permits real-time, noninvasive assessment of RV function, objective and comparative measures are underdeveloped, and appropriate animal models to study their utility are lacking. Longitudinal strain analysis is a novel echocardiographic method to quantify RV performance. Herein, we hypothesized that peak RV longitudinal strain would worsen in a bovine model of pulmonary hypertension compared with control animals. METHODS:Newborn Holstein calves were randomly chosen for induction of pulmonary hypertension versus control conditions. Pulmonary hypertension was induced by exposing animals to 14 days of hypoxia (equivalent to 4570 m above sea level or 430 mm Hg barometric pressure). Control animals were kept at ambient pressure/normoxia. At the end of the intervention, transthoracic echocardiography was performed in awake calves. Longitudinal wall strain was analyzed from modified apical 4-chamber views focused on the RV. Comparisons between measurements in hypoxic versus nonhypoxic conditions were performed using Student t test for independent samples and unequal variances. RESULTS:After 14 days at normoxic versus hypoxic conditions, 15 calves were examined with echocardiography. Pulmonary hypertension was confirmed by right heart catheterization and associated with reduced RV systolic function. Mean systolic strain measurements were compared in normoxia-exposed animals (n = 8) and hypoxia-exposed animals (n = 7). Peak global systolic longitudinal RV strain after hypoxia worsened compared to normoxia (−10.5% vs −16.1%, P = 0.0031). Peak RV free wall strain also worsened after hypoxia compared to normoxia (−9.6% vs −17.3%, P = 0.0031). Findings from strain analysis were confirmed by measurement of tricuspid annular peak systolic excursion. CONCLUSIONS:Peak longitudinal RV strain detected worsened RV function in animals with hypoxia-induced pulmonary hypertension compared with control animals. This relationship was demonstrated in the transthoracic echocardiographic 4-chamber view independently for the RV free wall and for the combination of the free and septal walls. This innovative model of bovine pulmonary hypertension may prove useful to compare different monitoring technologies for the assessment of early events of RV dysfunction. Further studies linking novel RV imaging applications with mechanistic and therapeutic approaches are needed.

SIMPLE PRESENCE OF AORTIC HOLODIASTOLIC FLOW REVERSAL IN CONGENITAL HEART DISEASE DOES NOT PREDICT MODERATE AORTIC INSUFFICIENCY: NOVEL EVALUATION OF THE REVERSE TO FORWARD FLOW RATIO BY ECHO COMPARED TO MAGNETIC RESONANCE IMAGING

Holodiastolic flow reversal (HDFR) in the descending aorta (DAO) is considered a sign of ≥ moderate aortic insufficiency (AI) in both adults and children. In congenital heart disease, our experience suggests this measure can overestimate AI when compared to cardiac magnetic resonance imaging (

An unusual location of a persistent vein of Marshall.

n 18-year-old young man was referred to our institution for surgical repair of an ascending aortic neurysm associated with a nonobstructive bicuspid aoric valve. His preoperative echocardiogram initially demnstrated what appeared to be an accessory left pulmoary vein that drained cranially into the innominate vein. he rest of his pulmonary venous anatomy was well seen nd drained normally to the left atrium. This prompted a magnetic resonance angiogram with hree-dimensional volume rendering (Fig 1). In addition o the aneurysmal ascending aorta, the magnetic resoance imaging revealed an ascending venous connection etween the left upper pulmonary vein and the innomiate vein. The characteristic of this vessel was of a ersistent vein of Marshall, the embryological remnant of he left anterior cardinal vein. At operation, the dissection lateral to the left pulmoary vein, in the expected location of a vertical vein of the ype usually associated with total anomalous pulmonary enous return (TAPVR), failed to yield anything. We then oted that a vessel was located in between the branch

Kawashima by Fenestrated Hemi-Fontan for Palliation Following Prior Stage I Norwood Operation

Single ventricle patients with interrupted inferior vena cava (IVC) and azygos continuation to the superior vena cava (SVC) are typically palliated with a bidirectional cavopulmonary shunt (BCPS), known as the Kawashima operation in this setting. Because the volume of venous blood directed to the pulmonary arteries is substantially greater in the presence of interrupted IVC, Kawashima procedures are commonly delayed to older age compared to other single ventricle patients undergoing BCPS. We report two young infant single ventricle patients with interrupted IVC and azygos continuation to the SVC who underwent stage I Norwood procedures for initial palliation. In both cases, a fenestrated hemi-Fontan procedure achieved successful Kawashima circulations.

Proximal Pulmonary Artery Evaluation in Infants With Shunt-Dependent Pulmonary Blood Flow: Computed Tomographic Angiography Versus Transthoracic Echocardiography:

Background: Infants with shunt-dependent pulmonary blood flow are at risk for developing proximal pulmonary artery (PA) stenosis, which may result in morbidity and mortality. Transthoracic echocardiography (TTE) is the primary means of surveillance for PA narrowing but has significant limitations and has not been compared to computed tomographic angiography (CTA)–derived measurements of the proximal PA anatomy in this population. Methods: A retrospective chart review identified infants with shunt-dependent pulmonary blood flow who had both TTE and CTA performed <14 days apart during a five-year period. Proximal right pulmonary artery (RPA) and left pulmonary artery (LPA) diameters were measured by TTE and CTA. Pulmonary artery z-score, linear and intraclass correlation (ICC) coefficients, and Bland-Altman plots were computed. Results: Seventeen pairs of studies were analyzed. The TTE and CTA proximal PA diameters had moderate linear correlation and agreement (R = 0.67, P ≤ .0001, ICC = 0.65); the RPA showed stronger correlation and agreement (R = 0.76, P = .0004, ICC = 0.72) than the LPA (R = 0.59, P = .01, ICC = 0.59). Computed tomographic angiography detected missed PA stenosis (Z score < −2) in five (14.7%) cases, four of which were on the LPA. Conclusion: In this study of infants with shunt-dependent pulmonary blood flow, TTE and CTA proximal PA diameters had only moderate correlation and agreement overall, which was worse when comparing LPA measurements. This resulted in missed PA stenosis by TTE. Computed tomographic angiography may be warranted in patients with poorly visualized PAs by TTE or suspicion for deficient pulmonary blood flow.

Erratum to: Preprocedural Risk Assessment Prior to PPVI with CMR and Cardiac CT

The original version of this article unfortunately contained a mistake. An co-author name (Daniel Vargas) was missing in the author group and was listed incorrectly as: Ladonna Malone, Brian Fonseca, Thomas Fagan, Jane Gralla, Neil Wilson, Micheal DiMaria, Uyen Truong, Lorna P. Browne The corrected author group is given below Ladonna Malone, Brian Fonseca, Thomas Fagan, Jane Gralla, Neil Wilson, Daniel Vargas, Micheal DiMaria, Uyen Truong, Lorna P. Browne

Apparent Aortic Stiffness in Children With Pulmonary Arterial HypertensionCLINICAL PERSPECTIVE

Background— Left ventricular dysfunction, mediated by ventricular interdependence, has been associated with negative outcomes in children with pulmonary arterial hypertension (PAH). Considering the dilation of the pulmonary arteries as a paramount sign of PAH, we hypothesized that the ascending aorta will present signs of apparent stiffness in children with PAH and that this effect may be because of mechanical interaction with the dilated main pulmonary artery (MPA). Methods and Results— Forty-two children with PAH and 26 age- and size-matched controls underwent comprehensive cardiac magnetic resonance evaluation. Assessment of aortic stiffness was evaluated by measuring pulse wave velocity, aortic strain, and distensibility. Children with PAH had significantly increased pulse wave velocity in the ascending aorta (3.4 versus 2.3 m/s for PAH and controls, respectively; P=0.001) and reduced aortic strain (23% versus 29%; P<0.0001) and distensibility (0.47 versus 0.64%/mm Hg; P=0.02). Indexed MPA diameter correlated with pulse wave velocity (P=0.04) and with aortic strain (P=0.02). The ratio of MPA to aortic size correlated with pulse wave velocity (P=0.0098), strain (P=0.0099), and distensibility (P=0.015). Furthermore, aortic relative area change was associated with left ventricular ejection fraction (P=0.045) and ventricular–vascular coupling ratio (P=0.042). Conclusions— Pediatric PAH patients have increased apparent ascending aortic stiffness, which was strongly associated with the degree of MPA distension. We speculate that distension of the MPA may play a major role in limiting full aortic expansion during systole, which modulates left ventricular performance and impacts systemic hemodynamics in pediatric PAH.