Safety and feasibility of deep sedation and general anaesthesia for cardiovascular magnetic resonance imaging studies in paediatric patients from 2 large tertiary European centres

Safety and feasibility of deep sedation and general anaesthesia for cardiovascular magnetic resonance imaging studies in paediatric patients from 2 large tertiary European centres | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Safety and feasibility of deep sedation and general anaesthesia for cardiovascular magnetic resonance imaging studies in paediatric patients from 2 large tertiary European centres Sylvia Krupickova, Mary Lane, Marcel Schmidt, Julieta Rancati, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7518455/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose To investigate the safety and feasibility of deep sedation(DS) and general anaesthesia(GA) for cardiovascular magnetic resonance(CMR) imaging in paediatric patients with congenital or acquired cardiac diseases. Methods This retrospective study of all consecutive patients less than 18 years of age who had DS for CMR examination at the University Hospital Schleswig-Holstein (Kiel,Germany) between 2010 and 2020 and CMR examination under GA at the Royal Brompton Hospital (London,UK) between 2013 and 2022. Data were collected using CMR reports, anaesthetic charts and medical records. Results Five-hundred twenty-two patients were in DS group and 171 in GA group. Most of the patients had congenital heart disease (86% in DS and 70% in GA group). There were overall 14 adverse events (2%); 8 (1.5%) in the DS group and 6 (3.5%) in GA group. This difference was not statistically significant (p = 0.122). Complications in the DS group included mild anaphylactic reactions in 3 patients, a severe coughing fit in 1 patient, increasing cyanosis in 3 single ventricle patients and suspected aspiration in 1 patient. In the GA group, hypotension requiring some intervention was present in 3 patients(4 scans). One patient(0.6%) had inadvertent endobronchial intubation. One patient with unrepaired double outlet right ventricle and multilevel pulmonary stenosis experienced a severe cyanotic spell on induction to anaesthesia and the scan had to be abandoned. Conclusion Both DS and GA can be used for CMR scans in paediatric patients with a low rate of complications. This however requires highly skilled teams who adhere strongly to the safety policies and guidelines set up by each hospital. general anaesthesia sedation cardiovascular magnetic resonance imaging congenital heart disease Figures Figure 1 Figure 2 Introduction Cardiovascular magnetic resonance (CMR) imaging is an integral part of the cardiovascular diagnostic process in paediatric patients with acquired and congenital heart disease (CHD). With the rapid emergence of new sequences and diagnostic techniques, CMR is increasingly used to significantly improve clinical patient management( 1 , 2 ). However, in younger paediatric patients and those unable to co-operate for both clinical and non-clinical reasons, CMR can be challenging as these patients often struggle to lie still during image acquisition and are unable to follow breathing commands. Motion and irregular breathing adversely impact CMR image quality and can make accurate quantitative cardiovascular measurements unattainable. CMR image acquisition in these patients is therefore typically performed with the use of general anaesthesia (GA) or deep sedation (DS). In a single centre study, both GA and DS have been found to be safe for CMR imaging( 3 ), but the GA group consisted of more critically ill patients which makes the comparability of the GA and DS groups more difficult( 3 ). Other studies showed that the use of GA in hospitalised patients is a risk factor for adverse events( 4 ), and that in paediatric patients with CHD who receive a GA for CMR, the complication rate is higher than in the general pediatric population due to underlying cardiac condition( 5 ). For sedation, propofol has been found to be an effective and efficient drug( 6 , 7 ), however side effects might be more common compared to phenobarbital( 7 ). For this study the following hypothesis was formulated: with a standardized approach, DS and GA are both safe and efficient for CMR imaging in paediatric patients with acquired and congenital heart disease. To test this hypothesis hospital records in two different hospitals with large paediatric CMR programmes were retrospectively analysed. Methods Patients All consecutive children and adolescents of 0–18 years of age who had DS for a CMR examination at the University Hospital Schleswig-Holstein (Kiel,Germany) between 2010 and 2020 and all paediatric patients who underwent a CMR examination under GA at the Royal Brompton Hospital (London, UK) between 2013 and 2022 were retrospectively reviewed and included. Data were collected using CMR reports, anaesthetic charts and medical records. Demographic data, cardiac diagnoses, the severity of congenital cardiac defects (defined as simple, moderate and severe)( 8 ), comorbidities and history of any cardiology or cardiac surgical procedures were all recorded. Adverse events were documented. Hypotension was defined as a decrease in more than 20% of the baseline blood pressure. Hypothermia was present if the body temperature decreased below 36 degrees C. The study was approved by the ethics committee of the Medical Faculty of the Christian Albrechts University, Kiel (approval date: 29/09/2021, reference number: D 597/21). The research has been conducted in accordance with the Declaration of Helsinki. Parents or guardians signed a research consent in both hospitals. Sedation protocol Sedation protocol For CMR under DS fasting guidelines similar to those described by the American Society of Anesthesiologists were used( 9 , 10 ). Midazolam was given as premedication followed by initiation of sedation with bolus doses of propofol. Sedation was maintained with continuous infusion of propofol using an MR compatible infusion pump (MRidium®, IRadimed Corporation, Florida, United States of America). Phenobarbital, ketamine or chloral hydrate was given in a minority of cases. ECG monitoring as well as monitoring of oxygen saturation and blood pressure was performed with a magnetic resonance (MR) compatible monitoring system (Expression MR, Philips Healthcare) throughout the examination. Supplemental nasal oxygen was given with a rate of 2–3 l/min. The response to sedation was measured using the Richmond Agitation-Sedation Scale (RASS)( 11 ). During the examinations a paediatric cardiologist with experience in CMR, a paediatrician or paediatric cardiologist with experience in paediatric intensive care medicine as well as a technician were present. General anaesthetic protocol Detailed internal guidelines for patients undergoing CMR under general anaesthesia were followed before, during and after the CMR scan under GA. Patients were admitted on the day of the CMR scan unless they had additional risks that required admission the night before, for example patients with shunt dependant pulmonary blood flow. These patients also received intravenous fluids overnight on a case by case basis. Another group of patients undergoing GA CMR were inpatients on the ward or intensive care unit (ICU) requiring CMR under GA during admission. Premedication with midazolam was considered in all patients other than small infants. Induction of anaesthesia was performed in the CMR anaesthetic room using either an inhalation technique with sevofluorane or intravenous technique. Following use of a non-depolarizing neuromuscular-blocking (NDNMB) agent, predominantly rocuronium, all patients were intubated in the anaesthetic room to facilitate multiple breath holding sequences required during CMR scans. Anaesthesia was maintained with sevoflurane or isofluorane and paralysis maintained using NDNMB agent intermittently as required during the procedure. In non-ventilated ICU patients, and those not requiring additional procedures under GA, muscle relaxation was reversed using neostigmine/glycopyrrolate or sugammadex once the scan was complete. An MR-conditional Ohmeda ventilator on the Aestiva MRI anaesthetic machine which operates in static fields of less than 30mT (300 Gauss) was used in all patients. The circuit has an extra-long inspiratory limb that loops back in the control room through the wave guide, specifically designed to facilitate breath-holds during the scan. MR conditional monitoring using the Philips Expression MR400 monitor is used from the start of the anaesthetic in the anaesthetic room. AAGBI (Association of Anaesthetists of Great Britain and Ireland) standard monitoring was adhered to with ECG, non-invasive blood pressure, oxygen saturation and gas analysis including capnometry, oxygen analysis and agent concentration. Continuous temperature measurement was performed using the FlexTEMP ll sensor. All patients received clear fluid (5-15mls/kg) during the anaesthetic. CMR scan CMR scanner DS scans were performed using a 3T scanner (Ingenia, Philips Healthcare), GA scans using a 3T scanner (Magnetom Vida, Siemens Healthineers) or 1.5T scanner (Magnetom Sola, Siemens Healthineers). Standard sequences were used with the protocols tailored to the clinical question. Gadolinium contrast agent for contrast angiography and/or late gadolinium enhancement was used in a subset of patients. Statistical analyses The software R version 4.0.3( 12 ) was used for the statistical analyses. All tests were performed two-sided and a significance level of 0.05 was chosen. Categorical data are shown as absolute frequencies and percentages, whereas continuous data were non-normally distributed and are presented as median with interquartile range. For the univariable analysis, Fisher’s exact test was applied for categorical and the Wilcoxon rank sum test for continuous data. A logistic regression analysis was performed to adjust for additional influence variables. Outcome was adverse event (yes/no). Influence variables were group (DS vs GA), weight, body mass index (BMI), oxygen saturation and the Warnes score. This analysis was applied with all variables included in the model and additionally a backwards selection with a p-value threshold of 0.05 was performed. Moreover, a propensity score analysis with matching was conducted. For this, the R package MatchIt was utilized( 13 ). The propensity score was calculated using a logistic regression model and covariables (weight, BMI, oxygen saturation and Warnes score). Results Demographic data and diagnoses Five-hundred twenty-two patients were in DS group and 171 in the GA group. Detailed demographic data are shown in Table 1 and age distribution separately in each group in Fig. 1 . Most of the patients had congenital heart disease (86% in DS group and 70% in GA group). The overview of the cardiac diseases in each group broken down to congenital and non-congenital diseases is depicted in Fig. 2 . 70% of the congenital conditions in the DS group and 56% in the GA group were of great complexity by Warnes classification. Table 1 Patient characteristics, p values correspond to univariable analysis, * Wilcoxon rank sum test, ** Fisher’s exact test Parameter Group I CMR under sedation (n = 522) Group II CMR under general anaesthesia (n = 171) P value Age (year) 5.0 [3.4; 8.2] 4.6 [2.5, 7] 0.011* Gender (female, n) 190 (36%) 67 (39%) Height (cm) 107.0 [97.0; 126.2] 103.0 [88.0; 116.8] 0.001* Weight (kg) 17.8 [14.0; 25.0] 17.0 [12.5; 21.7] 0.013* BSA (m 2 ) (Mosteller formula) 0.73 [0.61; 0.93] 0.70 [0.56; 0.83] BMI (kg/m 2 ) 15.6 [14.5; 16.6] 17.0 [12.5; 21.6] 0.764* Oxygen saturation (%) 94.0 [90.0; 97.0] 98.0 [94.0; 100] < 001* Application of gadolinium (n, %) 450 (86%) 142 (83%) Ejection fraction (%) 59 [53.0; 64] 60.0 [54.3; 65.8] Congenital heart disease (n, %) 447 (86%) 120 (70%) Warnes score - I - II - III 3 (1%) 109 (23%) 372 (77%) 5 (4%) 48 (40%) 67 (56%) < 0.001** Other non-congenital cardiac diseases (n, %) 74 (14%) 51 (30%) In the DS group, the most common cardiac defect was hypoplastic left heart syndrome (n = 203,39%), followed by tetralogy of Fallot (n = 61,12%) and transposition of the great arteries (n = 36,7%). Most patients had a single ventricle and had previously undergone completion of the Fontan circulation (n = 246,47%). Forty-one patients had associated syndromes such as VACTERL association (n = 7), trisomy 21 (n = 8), DiGeorge-syndrome (n = 15), Noonan syndrome (n = 1), Turner syndrome (n = 2), William syndrome (n = 2), Goldenhar syndrome (n = 3), Klinefelter syndrome (n = 1), Rubinstein-Taybi syndrome (n = 1), Kabuki syndrome (n = 1). In the GA group, at the time of CMR, 22 (18%) of the patients with congenital heart disease had an unrepaired condition, 41 (34%) were on single ventricle pathway and 57 (48%) had a history of complete repair. Sixty-one (36%) patients in GA group had associated comorbidities and/or syndromes, neurodevelopmental delay of unknown genetic cause (n = 18), autism spectrum disorder (n = 7), trisomy 21 (n = 6), DiGeorge syndrome (n = 6), Noonan syndrome (n = 6), William syndrome (n = 4), CHARGE association (n = 4) and 10 other genetic disorders). CMR scan In the GA group, 141 (82.5%) patients received gadolinium contrast agent with contrast angiography (104 patients) and/or late gadolinium enhancement (69 patients). Stress perfusion was performed in 7 CMR studies (5 positive). There were 3 positive studies in one patient with a stent in left coronary artery who presented in cardiac arrest due to severe stenosis of the left coronary artery, one positive study in a patient after arterial switch repair with single coronary artery and another positive study in a patient with anomalous origin of left coronary artery from right coronary sinus and intramural course. Additional procedures Fifty-five patients (32%) in the GA group have undergone additional procedures following the CMR scan under the same general anaesthesia. Brain MRI was performed together with the CMR in 13 patients. Thirty-four patients underwent cardiac catheterisation, 3 insertion of implantable loop recorder, 2 transoesophageal echocardiogram, 2 patients underwent non-cardiac intervention (dental extraction in 1 and operation of hydrocele in another 1). One 8 year-old patient with autism underwent CT before right ventricular to pulmonary artery conduit balloon valvuloplasty to delineate coronary artery anatomy. Deep sedation Most patients (n = 517,99%) received midazolam as premedication that was followed by propofol boluses and propofol infusion. Phenobarbital was used instead of midazolam in two patients and chloral hydrate in one patient. Ketamine instead of propofol was used in two patients. A RASS of 2 could be maintained during CMR. The average duration of the CMR scan was 95 ± 32 minutes. Anaesthetic procedure In the GA group, anaesthetic data was available for analysis from 158 patients. General anaesthesia was induced using inhalation of Sevofluorane in 89 patients and with intravenous drugs in 55 patients (54 propofol and 1 ketamine). The 14 remaining patients did not require induction as they were referred from intensive care unit. GA was then maintained using intermittent positive pressure ventilation (IPPV) with Sevofluorane in 95 patients and Isofluorane in 63 patients. Complications DS group Complications were documented in eight patients (1.5%). These complications comprised mild anaphylactic reactions in 3 patients, a severe coughing fit in 1 patient, increasing cyanosis in 3 single ventricle patients and suspected aspiration in 1 patient. None of the patients required admission to the intensive care unit or had a significantly prolonged hospital stay. The CMR scan was terminated early because of early awakening and agitation in 2.5% and coughing fits in 1.9%. GA group Based on risk assessment before CMR, 13 patients (8%) were considered as high risk for the general anaesthesia: two patients had severe pulmonary hypertension, 4 severe obstruction to the pulmonary flow, 3 severe left ventricular outflow tract obstruction and 4 significant left ventricular dysfunction. Hypotension requiring some intervention was present in 3 patients (4 scans) in the GA group. Two patients out of these were considered as high risk for general anaesthesia. A 15-month-old patient with unrepaired double outlet right ventricle and multilevel pulmonary stenosis experienced a severe cyanotic spell on induction to anaesthesia. Therefore, the scan was abandoned. Following this, a semi-urgent bidirectional Glenn was performed. The patient underwent a successful CMR scan under GA before full repair. One patient (0.6%) had inadvertent endobronchial intubation. Minor hypothermia during the scan was present in 56 (33%) patients. Management after the CMR scans In the group of patients with congenital heart disease, 57 required surgical procedures and 55 continued with conservative management following the CMR under GA. In the group of patients with non-congenital heart disease, CMR helped with diagnostic process in 36 patients and excluded cardiomyopathy/myocarditis in 10. Altogether 13 patients required further imaging. Comparison of adverse events between DS and GA groups There were overall 14 adverse events (2%); 8 (1.5%) in the DS group and 6 (3.5%) in the GA group (excluding minor hypothermia in GA group). This difference was not statistically significant (p = 0.122). All other variables except BMI showed a significant difference between the DS and GA group (Table 1 ). A logistic regression with outcome adverse event and influence variables group (DS vs GA), weight, BMI, oxygen saturation and Warnes score showed no significant results (p > 0.05 for all influence variables). When a backward selection was performed, no variable remained as significant in the model. A propensity score analysis was performed which generated matched data balanced with respect to weight, BMI, oxygen saturation and Warnes score in the two groups DS and GA. Comparison of the adverse events showed again no significant difference between the two groups (p = 0.497, odds ratio (95% confidence interval: 1.88 (0.303,11.7)). Discussion We present the feasibility and safety of CMR performed under DS or GA in 2 large volume paediatric cardiology tertiary centres. The overall reported risk of severe injury or death for a healthy child having an MRI scan under GA is extremely low, less than 1:100 000( 12 ). However, in children with underlying cardiac disease, this risk is significantly higher. The general anaesthetic can therefore pose more risk to patients with congenital and acquired heart disease than the CMR itself. Patient comorbidities, the severity of cardiac lesion, and functional status at the time of the GA for any non-cardiac procedure are the main factors determining risk, rather than the type of procedure itself( 13 ). Using the CHD classification based on residual lesion and functional status (pediatric database of the American College of Surgeons National Surgical Quality Improvement Program, ACS NSQIP Pediatric), it has been shown that patients with major CHD (after repair with residual findings) or severe CHD (eg patients with uncorrected cyanotic CHD, with pulmonary hypertension or ventricular dysfunction requiring medication) have significantly higher incidence of overall mortality when compared to matched controls (3.9% vs 1.7%,p < 0.001 and 8.2% vs 1.2%,p = 0.001, respectively). Importantly, no difference has been noted in overall mortality between patients with minor CHD (eg fully repaired CHD (without residual haemodynamic findings and normal biventricular circulation) or with small atrial/ventricular septal defects without hemodynamic effect) and matched controls( 14 ). Other studies have shown that there are several particularly high-risk cardiac conditions which are associated with higher rate of complications related to anaesthesia when patients undergo non-cardiac procedures( 15 ). These include left ventricular obstructive lesions, single ventricle lesions, pulmonary hypertension and ventricular dysfunction often complicating all former conditions. Aortic stenosis accounts for 16% of cardiac arrests in patients with congenital heart disease but with 62% mortality rate from cardiac arrest. William syndrome, when associated with aortic stenosis represents a particularly high-risk subgroup well known to be at extremely high risk of morbidity and mortality related to GA. Patients with single ventricle lesions are consistently identified as being at high risk. Single ventricle physiology accounts for 19% of cardiac arrests in patients with congenital heart disease associated with a 35% mortality rate in infants and children prior to completion of total cavopulmonary connection. Systemic or suprasystemic pulmonary hypertension is a high-risk factor for adverse events under general anaesthesia. Major events (defined as perioperative mortality or life-threatening incidents requiring immediate treatment), were found to be associated with severity of pulmonary hypertension (OR.2.04;P = 0.006) but not with aetiology. Incidence of intra- or postoperative cardiac arrest has been reported in 2.7% − 5% of cases( 16 ). Ventricular dysfunction itself often complicates cardiac diagnoses and thus increases risk of complications. In general, an ejection fraction of < 25% is considered high risk. Although, there are no data to support specific levels of ejection fraction being associated with a specific level of risk, it appears that it is more important to treat patients individually and understand the context and their current status. Our own data, collected between 2013 and 2022, show a low incidence of adverse events and lower than(4.4%) described in the literature( 4 ). There are several potential reasons for this. This is a consultant-led and delivered service with a small group of trained staff regularly delivering care to this cohort. In the past, all patients referred for the CMR have been discussed in the departmental paediatric cardiology and cardiac surgery meeting which included attendance of CMR consultant and anaesthetist performing the procedure. After establishing safe processes and education of the referring paediatric cardiologists, discussion at these meetings is now generally limited to only high-risk patients. Patients known to be at extremely high-risk are not scanned in the acute phase and their CMR is either postponed or alternative safer imaging modalities are used (although the patients‘ complexity has increased over the years). Internal hospital guidelines for patients undergoing CMR under GA have been established compliant with the most recent published advice from the Medicines and Healthcare products Regulatory Agency (MHRA)( 17 ), the Association of Anaesthetists of Great Britain and Ireland( 18 , 19 ) and guidelines for the provision of anaesthetic services from the Royal College of Anaesthetists (RCOA)( 20 ). In addition, new guidance has been published by the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI), Royal College of Paediatrics and Child Health (RCPCH) and Royal College of Anaesthetics (RCOA), detailing the process for informed consent in patients requiring diagnostic imaging procedures to be undertaken under general anaesthesia or sedation. This involves consideration of the risk for CMR prior to the scan and informed discussion with the parents, and ensures CMR is only undertaken under GA where there is likely to be clear benefit despite risks( 12 ). It is worth noting, that a holistic approach is taken when patients undergo CMR scan under GA and other procedures and imaging methods might be undertaken at the same time. This way the whole diagnostic process can be completed under one GA. Alternatively, cardiac catheterisation is performed after CMR either for diagnostic purposes or combined with an intervention. Conclusion We have shown that both DS and GA can be utilised for CMR scans in paediatric patients with a low rate of complication. This however requires a highly skilled team that adheres strongly to the safety policies set up by each hospital. Declarations Funding: None. Author Contribution S.K., M.L. and I.V. wrote the main manuscript text. J.R. prepared figures. M.S., J.R. and J.S. collected the data and analysed them. All authors reviewed the manuscript." Acknowledgement: None. References Dorfman AL, Geva T, Samyn MM, Greil G, Krishnamurthy R, Messroghli D et al (2022) SCMR expert consensus statement for cardiovascular magnetic resonance of acquired and non-structural pediatric heart disease. J Cardiovasc Magn Reson 24(1):44 Fogel MA, Anwar S, Broberg C, Browne L, Chung T, Johnson T et al (2022) Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the use of cardiovascular magnetic resonance in pediatric congenital and acquired heart disease. J Cardiovasc Magn Reson 24(1):37 Fogel MA, Weinberg PM, Parave E, Harris C, Montenegro L, Harris MA et al (2008) Deep sedation for cardiac magnetic resonance imaging: a comparison with cardiac anesthesia. J Pediatr 152(4):534 9.e1 Dorfman AL, Odegard KC, Powell AJ, Laussen PC, Geva T (2007) Risk factors for adverse events during cardiovascular magnetic resonance in congenital heart disease. J Cardiovasc Magn Reson 9(5):793–798 Stockton E, Hughes M, Broadhead M, Taylor A, McEwan A (2012) A prospective audit of safety issues associated with general anesthesia for pediatric cardiac magnetic resonance imaging. Paediatr Anaesth 22(11):1087–1093 Srinivasan M, Turmelle M, Depalma LM, Mao J, Carlson DW (2012) Procedural sedation for diagnostic imaging in children by pediatric hospitalists using propofol: analysis of the nature, frequency, and predictors of adverse events and interventions. J Pediatr 160(5):801–6e1 Mallory MD, Baxter AL, Kost SI (2009) Propofol vs pentobarbital for sedation of children undergoing magnetic resonance imaging: results from the Pediatric Sedation Research Consortium. Paediatr Anaesth 19(6):601–611 Warnes CA, Liberthson R, Danielson GK, Dore A, Harris L, Hoffman JI et al (2001) Task force 1: the changing profile of congenital heart disease in adult life. J Am Coll Cardiol 37(5):1170–1175 Bertram H, Sauer H, Haas N (2019) Empfehlungen und Standards für die Analgosedierung kinderkardiologischer Patienten. Monatsschrift Kinderheilkunde 167(10):916–924 Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. (2002) ;96(4):1004–1017 Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O'Neal PV, Keane KA et al (2002) The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 166(10):1338–1344 R Core Team (2020) R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL https://www.R-project.org/ Ho D, Imai K, King G, Stuart E (2011) MatchIt: Nonparametric preprocessing for parametric causal inference. 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Paediatr Anaesth 29(5):426–434 Bernier ML, Jacob AI, Collaco JM, McGrath-Morrow SA, Romer LH, Unegbu CC (2018) Perioperative events in children with pulmonary hypertension undergoing non-cardiac procedures. Pulm Circ 8:1–10 MHRA (2021) Device Bulletin: Safety guidelines for magnetic resonance imaging equipment in clinical use. In. London; 4th Ediction, February Association of Anaesthetists of Great Britain and Ireland.Immediate Post-anaesthesia Recovery 2013 (2013) Anaesthesia ; 68: pages 288 – 97. Guidelines for the safe provision of anaesthesia in magnetic resonance units 2019 (2019) 74, 638–650 Guidelines for the Provision of Anaesthetic Services (GPAS) (2023) The Royal College of Anaesthetists. https://www.rcoa.ac.uk/gpas/chapter-7 , 10 Additional Declarations No competing interests reported. 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Trust","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"","lastName":"Rigby","suffix":""},{"id":513237398,"identity":"831dd248-61fc-4b9e-b54a-4af6c6e02cdc","order_by":8,"name":"Piers Daubeney","email":"","orcid":"","institution":"Royal Brompton Hospital, Guy's and St Thomas' NHS Foundation Trust","correspondingAuthor":false,"prefix":"","firstName":"Piers","middleName":"","lastName":"Daubeney","suffix":""},{"id":513237400,"identity":"04f2f5f2-53eb-480d-a1ee-9414b194f39d","order_by":9,"name":"Anselm Uebing","email":"","orcid":"","institution":"University Hospital Schleswig-Holstein","correspondingAuthor":false,"prefix":"","firstName":"Anselm","middleName":"","lastName":"Uebing","suffix":""},{"id":513237402,"identity":"f687e231-4299-4795-8aa2-3bb7683c6514","order_by":10,"name":"Dominik Daniel Gabbert","email":"","orcid":"","institution":"University Hospital Schleswig-Holstein","correspondingAuthor":false,"prefix":"","firstName":"Dominik","middleName":"Daniel","lastName":"Gabbert","suffix":""},{"id":513237404,"identity":"8779d3e8-495e-4177-b283-99d90eac78ce","order_by":11,"name":"Dudley J Pennell","email":"","orcid":"","institution":"Imperial College","correspondingAuthor":false,"prefix":"","firstName":"Dudley","middleName":"J","lastName":"Pennell","suffix":""},{"id":513237405,"identity":"afa8ee7a-602b-4c56-b5cd-a19990f80735","order_by":12,"name":"Inga Voges","email":"","orcid":"","institution":"University Hospital Schleswig-Holstein","correspondingAuthor":false,"prefix":"","firstName":"Inga","middleName":"","lastName":"Voges","suffix":""}],"badges":[],"createdAt":"2025-09-02 13:53:59","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7518455/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7518455/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91306152,"identity":"ba0926e1-d2a7-4ae5-b85e-5f58c0cf0cb6","added_by":"auto","created_at":"2025-09-15 06:30:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":257271,"visible":true,"origin":"","legend":"\u003cp\u003eAge distribution for patients undergoing sedation (1A) and general anaesthesia (1B). GA general anaesthesia\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7518455/v1/b6eb2ebc7a0907cb0a8ffefa.png"},{"id":91306153,"identity":"8b6638c5-cce9-4bfc-96f2-61667f8813e3","added_by":"auto","created_at":"2025-09-15 06:30:49","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":401167,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of congenital heart disease in the sedation (2A) and GA groups (2B) and non-congenital heart disease in the sedation (2C) and GA groups (2D) at the Royal Brompton Hospital and University Hospital Schleswig-Holstein ARVC arrhythmogenic right ventricular dysplasia; GA general anaesthesia; ccTGA congenitally corrected transposition of great arteries, COA coarctation of aorta, DCM dilated cardiomyopathy; DORV double outlet right ventricle; HCM hypertrophic cardiomyopathy; HLHS hypoplastic left heart syndrome; LVNC left ventricular non-compaction; PA pulmonary atresia; TOF Tetralogy of Fallot; TGA transposition of great arteries; VSD ventricular septal defect; PIMS paediatric inflammatory multisystem syndrome\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7518455/v1/fce816788d14130f75431eb2.png"},{"id":91784224,"identity":"69f6073d-504e-4131-af32-acb2a3dc8089","added_by":"auto","created_at":"2025-09-21 07:01:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1159536,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7518455/v1/f092c9b3-a975-4621-8d08-15eda642095b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Safety and feasibility of deep sedation and general anaesthesia for cardiovascular magnetic resonance imaging studies in paediatric patients from 2 large tertiary European centres","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCardiovascular magnetic resonance (CMR) imaging is an integral part of the cardiovascular diagnostic process in paediatric patients with acquired and congenital heart disease (CHD). With the rapid emergence of new sequences and diagnostic techniques, CMR is increasingly used to significantly improve clinical patient management(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). However, in younger paediatric patients and those unable to co-operate for both clinical and non-clinical reasons, CMR can be challenging as these patients often struggle to lie still during image acquisition and are unable to follow breathing commands. Motion and irregular breathing adversely impact CMR image quality and can make accurate quantitative cardiovascular measurements unattainable. CMR image acquisition in these patients is therefore typically performed with the use of general anaesthesia (GA) or deep sedation (DS). In a single centre study, both GA and DS have been found to be safe for CMR imaging(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), but the GA group consisted of more critically ill patients which makes the comparability of the GA and DS groups more difficult(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Other studies showed that the use of GA in hospitalised patients is a risk factor for adverse events(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), and that in paediatric patients with CHD who receive a GA for CMR, the complication rate is higher than in the general pediatric population due to underlying cardiac condition(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). For sedation, propofol has been found to be an effective and efficient drug(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), however side effects might be more common compared to phenobarbital(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFor this study the following hypothesis was formulated: with a standardized approach, DS and GA are both safe and efficient for CMR imaging in paediatric patients with acquired and congenital heart disease. To test this hypothesis hospital records in two different hospitals with large paediatric CMR programmes were retrospectively analysed.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003ePatients\u003c/h2\u003e\u003cp\u003eAll consecutive children and adolescents of 0\u0026ndash;18 years of age who had DS for a CMR examination at the University Hospital Schleswig-Holstein (Kiel,Germany) between 2010 and 2020 and all paediatric patients who underwent a CMR examination under GA at the Royal Brompton Hospital (London, UK) between 2013 and 2022 were retrospectively reviewed and included.\u003c/p\u003e\u003cp\u003eData were collected using CMR reports, anaesthetic charts and medical records.\u003c/p\u003e\u003cp\u003eDemographic data, cardiac diagnoses, the severity of congenital cardiac defects (defined as simple, moderate and severe)(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), comorbidities and history of any cardiology or cardiac surgical procedures were all recorded. Adverse events were documented. Hypotension was defined as a decrease in more than 20% of the baseline blood pressure. Hypothermia was present if the body temperature decreased below 36 degrees C.\u003c/p\u003e\u003cp\u003e The study was approved by the ethics committee of the Medical Faculty of the Christian Albrechts University, Kiel (approval date: 29/09/2021, reference number: D 597/21). The research has been conducted in accordance with the Declaration of Helsinki. Parents or guardians signed a research consent in both hospitals.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSedation protocol\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003eSedation protocol\u003c/div\u003e\u003cp\u003eFor CMR under DS fasting guidelines similar to those described by the American Society of Anesthesiologists were used(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Midazolam was given as premedication followed by initiation of sedation with bolus doses of propofol. Sedation was maintained with continuous infusion of propofol using an MR compatible infusion pump (MRidium\u0026reg;, IRadimed Corporation, Florida, United States of America). Phenobarbital, ketamine or chloral hydrate was given in a minority of cases. ECG monitoring as well as monitoring of oxygen saturation and blood pressure was performed with a magnetic resonance (MR) compatible monitoring system (Expression MR, Philips Healthcare) throughout the examination. Supplemental nasal oxygen was given with a rate of 2\u0026ndash;3 l/min. The response to sedation was measured using the Richmond Agitation-Sedation Scale (RASS)(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). During the examinations a paediatric cardiologist with experience in CMR, a paediatrician or paediatric cardiologist with experience in paediatric intensive care medicine as well as a technician were present.\u003c/p\u003e\n\u003ch3\u003eGeneral anaesthetic protocol\u003c/h3\u003e\n\u003cp\u003e Detailed internal guidelines for patients undergoing CMR under general anaesthesia were followed before, during and after the CMR scan under GA. Patients were admitted on the day of the CMR scan unless they had additional risks that required admission the night before, for example patients with shunt dependant pulmonary blood flow. These patients also received intravenous fluids overnight on a case by case basis. Another group of patients undergoing GA CMR were inpatients on the ward or intensive care unit (ICU) requiring CMR under GA during admission.\u003c/p\u003e\u003cp\u003ePremedication with midazolam was considered in all patients other than small infants. Induction of anaesthesia was performed in the CMR anaesthetic room using either an inhalation technique with sevofluorane or intravenous technique. Following use of a non-depolarizing neuromuscular-blocking (NDNMB) agent, predominantly rocuronium, all patients were intubated in the anaesthetic room to facilitate multiple breath holding sequences required during CMR scans. Anaesthesia was maintained with sevoflurane or isofluorane and paralysis maintained using NDNMB agent intermittently as required during the procedure. In non-ventilated ICU patients, and those not requiring additional procedures under GA, muscle relaxation was reversed using neostigmine/glycopyrrolate or sugammadex once the scan was complete. An MR-conditional Ohmeda ventilator on the Aestiva MRI anaesthetic machine which operates in static fields of less than 30mT (300 Gauss) was used in all patients. The circuit has an extra-long inspiratory limb that loops back in the control room through the wave guide, specifically designed to facilitate breath-holds during the scan. MR conditional monitoring using the Philips Expression MR400 monitor is used from the start of the anaesthetic in the anaesthetic room. AAGBI (Association of Anaesthetists of Great Britain and Ireland) standard monitoring was adhered to with ECG, non-invasive blood pressure, oxygen saturation and gas analysis including capnometry, oxygen analysis and agent concentration. Continuous temperature measurement was performed using the FlexTEMP ll sensor. All patients received clear fluid (5-15mls/kg) during the anaesthetic.\u003c/p\u003e\n\u003ch3\u003eCMR scan\u003c/h3\u003e\n\u003cp\u003eCMR scanner\u003c/p\u003e\u003cp\u003eDS scans were performed using a 3T scanner (Ingenia, Philips Healthcare), GA scans using a 3T scanner (Magnetom Vida, Siemens Healthineers) or 1.5T scanner (Magnetom Sola, Siemens Healthineers). Standard sequences were used with the protocols tailored to the clinical question. Gadolinium contrast agent for contrast angiography and/or late gadolinium enhancement was used in a subset of patients.\u003c/p\u003e\n\u003ch3\u003eStatistical analyses\u003c/h3\u003e\n\u003cp\u003eThe software R version 4.0.3(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e12\u003c/span\u003e) was used for the statistical analyses. All tests were performed two-sided and a significance level of 0.05 was chosen. Categorical data are shown as absolute frequencies and percentages, whereas continuous data were non-normally distributed and are presented as median with interquartile range. For the univariable analysis, Fisher\u0026rsquo;s exact test was applied for categorical and the Wilcoxon rank sum test for continuous data. A logistic regression analysis was performed to adjust for additional influence variables. Outcome was adverse event (yes/no). Influence variables were group (DS vs GA), weight, body mass index (BMI), oxygen saturation and the Warnes score. This analysis was applied with all variables included in the model and additionally a backwards selection with a p-value threshold of 0.05 was performed.\u003c/p\u003e\u003cp\u003eMoreover, a propensity score analysis with matching was conducted. For this, the R package MatchIt was utilized(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The propensity score was calculated using a logistic regression model and covariables (weight, BMI, oxygen saturation and Warnes score).\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eDemographic data and diagnoses\u003c/h2\u003e\u003cp\u003eFive-hundred twenty-two patients were in DS group and 171 in the GA group. Detailed demographic data are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and age distribution separately in each group in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Most of the patients had congenital heart disease (86% in DS group and 70% in GA group). The overview of the cardiac diseases in each group broken down to congenital and non-congenital diseases is depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. 70% of the congenital conditions in the DS group and 56% in the GA group were of great complexity by Warnes classification.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatient characteristics, p values correspond to univariable analysis, * Wilcoxon rank sum test, ** Fisher\u0026rsquo;s exact test\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParameter\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGroup I\u003c/p\u003e\u003cp\u003eCMR under sedation (n\u0026thinsp;=\u0026thinsp;522)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGroup II\u003c/p\u003e\u003cp\u003eCMR under general anaesthesia (n\u0026thinsp;=\u0026thinsp;171)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (year)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.0 [3.4; 8.2]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.6 [2.5, 7]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.011*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender (female, n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e190 (36%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e67 (39%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeight (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e107.0 [97.0; 126.2]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e103.0 [88.0; 116.8]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeight (kg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17.8 [14.0; 25.0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17.0 [12.5; 21.7]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.013*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBSA (m\u003csup\u003e2\u003c/sup\u003e) (Mosteller formula)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.73 [0.61; 0.93]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.70 [0.56; 0.83]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15.6 [14.5; 16.6]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17.0 [12.5; 21.6]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.764*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOxygen saturation (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e94.0 [90.0; 97.0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e98.0 [94.0; 100]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eApplication of gadolinium (n, %)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e450 (86%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e142 (83%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEjection fraction (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e59 [53.0; 64]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e60.0 [54.3; 65.8]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCongenital heart disease (n, %)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e447 (86%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e120 (70%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWarnes score\u003c/p\u003e\u003cp\u003e- I\u003c/p\u003e\u003cp\u003e- II\u003c/p\u003e\u003cp\u003e- III\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cbr\u003e\u003cp\u003e3 (1%)\u003c/p\u003e\u003cp\u003e109 (23%)\u003c/p\u003e\u003cp\u003e372 (77%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cbr\u003e\u003cp\u003e5 (4%)\u003c/p\u003e\u003cp\u003e48 (40%)\u003c/p\u003e\u003cp\u003e67 (56%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther non-congenital cardiac diseases (n, %)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e74 (14%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51 (30%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIn the DS group, the most common cardiac defect was hypoplastic left heart syndrome (n\u0026thinsp;=\u0026thinsp;203,39%), followed by tetralogy of Fallot (n\u0026thinsp;=\u0026thinsp;61,12%) and transposition of the great arteries (n\u0026thinsp;=\u0026thinsp;36,7%). Most patients had a single ventricle and had previously undergone completion of the Fontan circulation (n\u0026thinsp;=\u0026thinsp;246,47%). Forty-one patients had associated syndromes such as VACTERL association (n\u0026thinsp;=\u0026thinsp;7), trisomy 21 (n\u0026thinsp;=\u0026thinsp;8), DiGeorge-syndrome (n\u0026thinsp;=\u0026thinsp;15), Noonan syndrome (n\u0026thinsp;=\u0026thinsp;1), Turner syndrome (n\u0026thinsp;=\u0026thinsp;2), William syndrome (n\u0026thinsp;=\u0026thinsp;2), Goldenhar syndrome (n\u0026thinsp;=\u0026thinsp;3), Klinefelter syndrome (n\u0026thinsp;=\u0026thinsp;1), Rubinstein-Taybi syndrome (n\u0026thinsp;=\u0026thinsp;1), Kabuki syndrome (n\u0026thinsp;=\u0026thinsp;1).\u003c/p\u003e\u003cp\u003eIn the GA group, at the time of CMR, 22 (18%) of the patients with congenital heart disease had an unrepaired condition, 41 (34%) were on single ventricle pathway and 57 (48%) had a history of complete repair. Sixty-one (36%) patients in GA group had associated comorbidities and/or syndromes, neurodevelopmental delay of unknown genetic cause (n\u0026thinsp;=\u0026thinsp;18), autism spectrum disorder (n\u0026thinsp;=\u0026thinsp;7), trisomy 21 (n\u0026thinsp;=\u0026thinsp;6), DiGeorge syndrome (n\u0026thinsp;=\u0026thinsp;6), Noonan syndrome (n\u0026thinsp;=\u0026thinsp;6), William syndrome (n\u0026thinsp;=\u0026thinsp;4), CHARGE association (n\u0026thinsp;=\u0026thinsp;4) and 10 other genetic disorders).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eCMR scan\u003c/h3\u003e\n\u003cp\u003eIn the GA group, 141 (82.5%) patients received gadolinium contrast agent with contrast angiography (104 patients) and/or late gadolinium enhancement (69 patients). Stress perfusion was performed in 7 CMR studies (5 positive). There were 3 positive studies in one patient with a stent in left coronary artery who presented in cardiac arrest due to severe stenosis of the left coronary artery, one positive study in a patient after arterial switch repair with single coronary artery and another positive study in a patient with anomalous origin of left coronary artery from right coronary sinus and intramural course.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eAdditional procedures\u003c/h2\u003e\u003cp\u003eFifty-five patients (32%) in the GA group have undergone additional procedures following the CMR scan under the same general anaesthesia. Brain MRI was performed together with the CMR in 13 patients. Thirty-four patients underwent cardiac catheterisation, 3 insertion of implantable loop recorder, 2 transoesophageal echocardiogram, 2 patients underwent non-cardiac intervention (dental extraction in 1 and operation of hydrocele in another 1). One 8 year-old patient with autism underwent CT before right ventricular to pulmonary artery conduit balloon valvuloplasty to delineate coronary artery anatomy.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eDeep sedation\u003c/h2\u003e\u003cp\u003eMost patients (n\u0026thinsp;=\u0026thinsp;517,99%) received midazolam as premedication that was followed by propofol boluses and propofol infusion. Phenobarbital was used instead of midazolam in two patients and chloral hydrate in one patient. Ketamine instead of propofol was used in two patients. A RASS of 2 could be maintained during CMR. The average duration of the CMR scan was 95\u0026thinsp;\u0026plusmn;\u0026thinsp;32 minutes.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eAnaesthetic procedure\u003c/h2\u003e\u003cp\u003eIn the GA group, anaesthetic data was available for analysis from 158 patients. General anaesthesia was induced using inhalation of Sevofluorane in 89 patients and with intravenous drugs in 55 patients (54 propofol and 1 ketamine). The 14 remaining patients did not require induction as they were referred from intensive care unit.\u003c/p\u003e\u003cp\u003eGA was then maintained using intermittent positive pressure ventilation (IPPV) with Sevofluorane in 95 patients and Isofluorane in 63 patients.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eComplications\u003c/h2\u003e\u003cp\u003eDS group\u003c/p\u003e\u003cp\u003eComplications were documented in eight patients (1.5%). These complications comprised mild anaphylactic reactions in 3 patients, a severe coughing fit in 1 patient, increasing cyanosis in 3 single ventricle patients and suspected aspiration in 1 patient.\u003c/p\u003e\u003cp\u003eNone of the patients required admission to the intensive care unit or had a significantly prolonged hospital stay.\u003c/p\u003e\u003cp\u003eThe CMR scan was terminated early because of early awakening and agitation in 2.5% and coughing fits in 1.9%.\u003c/p\u003e\u003cp\u003eGA group\u003c/p\u003e\u003cp\u003eBased on risk assessment before CMR, 13 patients (8%) were considered as high risk for the general anaesthesia: two patients had severe pulmonary hypertension, 4 severe obstruction to the pulmonary flow, 3 severe left ventricular outflow tract obstruction and 4 significant left ventricular dysfunction.\u003c/p\u003e\u003cp\u003eHypotension requiring some intervention was present in 3 patients (4 scans) in the GA group. Two patients out of these were considered as high risk for general anaesthesia.\u003c/p\u003e\u003cp\u003eA 15-month-old patient with unrepaired double outlet right ventricle and multilevel pulmonary stenosis experienced a severe cyanotic spell on induction to anaesthesia. Therefore, the scan was abandoned. Following this, a semi-urgent bidirectional Glenn was performed. The patient underwent a successful CMR scan under GA before full repair.\u003c/p\u003e\u003cp\u003eOne patient (0.6%) had inadvertent endobronchial intubation. Minor hypothermia during the scan was present in 56 (33%) patients.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eManagement after the CMR scans\u003c/h2\u003e\u003cp\u003eIn the group of patients with congenital heart disease, 57 required surgical procedures and 55 continued with conservative management following the CMR under GA. In the group of patients with non-congenital heart disease, CMR helped with diagnostic process in 36 patients and excluded cardiomyopathy/myocarditis in 10. Altogether 13 patients required further imaging.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eComparison of adverse events between DS and GA groups\u003c/h2\u003e\u003cp\u003eThere were overall 14 adverse events (2%); 8 (1.5%) in the DS group and 6 (3.5%) in the GA group (excluding minor hypothermia in GA group). This difference was not statistically significant (p\u0026thinsp;=\u0026thinsp;0.122). All other variables except BMI showed a significant difference between the DS and GA group (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). A logistic regression with outcome adverse event and influence variables group (DS vs GA), weight, BMI, oxygen saturation and Warnes score showed no significant results (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05 for all influence variables). When a backward selection was performed, no variable remained as significant in the model. A propensity score analysis was performed which generated matched data balanced with respect to weight, BMI, oxygen saturation and Warnes score in the two groups DS and GA. Comparison of the adverse events showed again no significant difference between the two groups (p\u0026thinsp;=\u0026thinsp;0.497, odds ratio (95% confidence interval: 1.88 (0.303,11.7)).\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe present the feasibility and safety of CMR performed under DS or GA in 2 large volume paediatric cardiology tertiary centres.\u003c/p\u003e\u003cp\u003eThe overall reported risk of severe injury or death for a healthy child having an MRI scan under GA is extremely low, less than 1:100 000(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e12\u003c/span\u003e). However, in children with underlying cardiac disease, this risk is significantly higher. The general anaesthetic can therefore pose more risk to patients with congenital and acquired heart disease than the CMR itself. Patient comorbidities, the severity of cardiac lesion, and functional status at the time of the GA for any non-cardiac procedure are the main factors determining risk, rather than the type of procedure itself(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Using the CHD classification based on residual lesion and functional status (pediatric database of the American College of Surgeons National Surgical Quality Improvement Program, ACS NSQIP Pediatric), it has been shown that patients with major CHD (after repair with residual findings) or severe CHD (eg patients with uncorrected cyanotic CHD, with pulmonary hypertension or ventricular dysfunction requiring medication) have significantly higher incidence of overall mortality when compared to matched controls (3.9% vs 1.7%,p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and 8.2% vs 1.2%,p\u0026thinsp;=\u0026thinsp;0.001, respectively). Importantly, no difference has been noted in overall mortality between patients with minor CHD (eg fully repaired CHD (without residual haemodynamic findings and normal biventricular circulation) or with small atrial/ventricular septal defects without hemodynamic effect) and matched controls(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOther studies have shown that there are several particularly high-risk cardiac conditions which are associated with higher rate of complications related to anaesthesia when patients undergo non-cardiac procedures(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e15\u003c/span\u003e). These include left ventricular obstructive lesions, single ventricle lesions, pulmonary hypertension and ventricular dysfunction often complicating all former conditions. Aortic stenosis accounts for 16% of cardiac arrests in patients with congenital heart disease but with 62% mortality rate from cardiac arrest. William syndrome, when associated with aortic stenosis represents a particularly high-risk subgroup well known to be at extremely high risk of morbidity and mortality related to GA. Patients with single ventricle lesions are consistently identified as being at high risk. Single ventricle physiology accounts for 19% of cardiac arrests in patients with congenital heart disease associated with a 35% mortality rate in infants and children prior to completion of total cavopulmonary connection. Systemic or suprasystemic pulmonary hypertension is a high-risk factor for adverse events under general anaesthesia. Major events (defined as perioperative mortality or life-threatening incidents requiring immediate treatment), were found to be associated with severity of pulmonary hypertension (OR.2.04;P\u0026thinsp;=\u0026thinsp;0.006) but not with aetiology. Incidence of intra- or postoperative cardiac arrest has been reported in 2.7% \u0026minus;\u0026thinsp;5% of cases(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eVentricular dysfunction itself often complicates cardiac diagnoses and thus increases risk of complications. In general, an ejection fraction of \u0026lt;\u0026thinsp;25% is considered high risk. Although, there are no data to support specific levels of ejection fraction being associated with a specific level of risk, it appears that it is more important to treat patients individually and understand the context and their current status.\u003c/p\u003e\u003cp\u003eOur own data, collected between 2013 and 2022, show a low incidence of adverse events and lower than(4.4%) described in the literature(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). There are several potential reasons for this. This is a consultant-led and delivered service with a small group of trained staff regularly delivering care to this cohort. In the past, all patients referred for the CMR have been discussed in the departmental paediatric cardiology and cardiac surgery meeting which included attendance of CMR consultant and anaesthetist performing the procedure. After establishing safe processes and education of the referring paediatric cardiologists, discussion at these meetings is now generally limited to only high-risk patients. Patients known to be at extremely high-risk are not scanned in the acute phase and their CMR is either postponed or alternative safer imaging modalities are used (although the patients\u0026lsquo; complexity has increased over the years).\u003c/p\u003e\u003cp\u003eInternal hospital guidelines for patients undergoing CMR under GA have been established compliant with the most recent published advice from the Medicines and Healthcare products Regulatory Agency (MHRA)(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e17\u003c/span\u003e), the Association of Anaesthetists of Great Britain and Ireland(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e19\u003c/span\u003e) and guidelines for the provision of anaesthetic services from the Royal College of Anaesthetists (RCOA)(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e20\u003c/span\u003e). In addition, new guidance has been published by the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI), Royal College of Paediatrics and Child Health (RCPCH) and Royal College of Anaesthetics (RCOA), detailing the process for informed consent in patients requiring diagnostic imaging procedures to be undertaken under general anaesthesia or sedation. This involves consideration of the risk for CMR prior to the scan and informed discussion with the parents, and ensures CMR is only undertaken under GA where there is likely to be clear benefit despite risks(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIt is worth noting, that a holistic approach is taken when patients undergo CMR scan under GA and other procedures and imaging methods might be undertaken at the same time. This way the whole diagnostic process can be completed under one GA. Alternatively, cardiac catheterisation is performed after CMR either for diagnostic purposes or combined with an intervention.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003cp\u003eWe have shown that both DS and GA can be utilised for CMR scans in paediatric patients with a low rate of complication. This however requires a highly skilled team that adheres strongly to the safety policies set up by each hospital.\u003c/p\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eNone.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eS.K., M.L. and I.V. wrote the main manuscript text. J.R. prepared figures. M.S., J.R. and J.S. collected the data and analysed them. All authors reviewed the manuscript.\"\u003c/p\u003e\u003ch2\u003eAcknowledgement:\u003c/h2\u003e\u003cp\u003eNone.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDorfman AL, Geva T, Samyn MM, Greil G, Krishnamurthy R, Messroghli D et al (2022) SCMR expert consensus statement for cardiovascular magnetic resonance of acquired and non-structural pediatric heart disease. J Cardiovasc Magn Reson 24(1):44\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFogel MA, Anwar S, Broberg C, Browne L, Chung T, Johnson T et al (2022) Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the use of cardiovascular magnetic resonance in pediatric congenital and acquired heart disease. J Cardiovasc Magn Reson 24(1):37\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFogel MA, Weinberg PM, Parave E, Harris C, Montenegro L, Harris MA et al (2008) Deep sedation for cardiac magnetic resonance imaging: a comparison with cardiac anesthesia. J Pediatr 152(4):534 9.e1\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDorfman AL, Odegard KC, Powell AJ, Laussen PC, Geva T (2007) Risk factors for adverse events during cardiovascular magnetic resonance in congenital heart disease. J Cardiovasc Magn Reson 9(5):793\u0026ndash;798\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStockton E, Hughes M, Broadhead M, Taylor A, McEwan A (2012) A prospective audit of safety issues associated with general anesthesia for pediatric cardiac magnetic resonance imaging. Paediatr Anaesth 22(11):1087\u0026ndash;1093\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSrinivasan M, Turmelle M, Depalma LM, Mao J, Carlson DW (2012) Procedural sedation for diagnostic imaging in children by pediatric hospitalists using propofol: analysis of the nature, frequency, and predictors of adverse events and interventions. J Pediatr 160(5):801\u0026ndash;6e1\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMallory MD, Baxter AL, Kost SI (2009) Propofol vs pentobarbital for sedation of children undergoing magnetic resonance imaging: results from the Pediatric Sedation Research Consortium. Paediatr Anaesth 19(6):601\u0026ndash;611\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWarnes CA, Liberthson R, Danielson GK, Dore A, Harris L, Hoffman JI et al (2001) Task force 1: the changing profile of congenital heart disease in adult life. J Am Coll Cardiol 37(5):1170\u0026ndash;1175\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBertram H, Sauer H, Haas N (2019) Empfehlungen und Standards f\u0026uuml;r die Analgosedierung kinderkardiologischer Patienten. Monatsschrift Kinderheilkunde 167(10):916\u0026ndash;924\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePractice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. (2002) ;96(4):1004\u0026ndash;1017\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSessler CN, Gosnell MS, Grap MJ, Brophy GM, O'Neal PV, Keane KA et al (2002) The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 166(10):1338\u0026ndash;1344\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eR Core Team (2020) R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.R-project.org/\u003c/span\u003e\u003cspan address=\"https://www.R-project.org/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHo D, Imai K, King G, Stuart E (2011) MatchIt: Nonparametric preprocessing for parametric causal inference. J Stat Software_ 42(8):1\u0026ndash;28\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eArel-Bundock V, Greifer N, Heiss A (2024) How to Interpret Statistical Models Using marginaleffects for R and Python._Journal of Statistical Software_, 111(9), 1\u0026ndash;32\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRoyal College of Anaesthetics (2021) Paediatric Imaging under general anaesthetic. November\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFaraoni D, Zou X, DiNardo JA, Nasr VG (2020) Integration of the intrinsic surgical risk with patient comorbidities and severity of congenital cardiac disease does not improve risk stratification in children undergoing noncardiac surgery. Anesth Analg 131(4):1083\u0026ndash;1089\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFaraoni D, Zurakowski D, Vo D, Goobie SM, Yuki K, Brown ML, DiNardo JA (2016) Post-Operative Outcomes in Children With and Without Congenital Heart Disease Undergoing Noncardiac Surgery. J Am Coll Cardiol 67(7):793\u0026ndash;801\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTaylor D, Habre W (2019) Risk associated with anesthesia for noncardiac surgery in children with congenital heart disease. 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London; 4th Ediction, February\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAssociation of Anaesthetists of Great Britain and Ireland.Immediate Post-anaesthesia Recovery 2013 (2013) Anaesthesia ; 68: pages 288\u0026thinsp;\u0026ndash;\u0026thinsp;97.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGuidelines for the safe provision of anaesthesia in magnetic resonance units 2019 (2019) 74, 638\u0026ndash;650\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGuidelines for the Provision of Anaesthetic Services (GPAS) (2023) The Royal College of Anaesthetists. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.rcoa.ac.uk/gpas/chapter-7\u003c/span\u003e\u003cspan address=\"https://www.rcoa.ac.uk/gpas/chapter-7\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e, 10\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"general anaesthesia, sedation, cardiovascular magnetic resonance imaging, congenital heart disease","lastPublishedDoi":"10.21203/rs.3.rs-7518455/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7518455/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eTo investigate the safety and feasibility of deep sedation(DS) and general anaesthesia(GA) for cardiovascular magnetic resonance(CMR) imaging in paediatric patients with congenital or acquired cardiac diseases.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis retrospective study of all consecutive patients less than 18 years of age who had DS for CMR examination at the University Hospital Schleswig-Holstein (Kiel,Germany) between 2010 and 2020 and CMR examination under GA at the Royal Brompton Hospital (London,UK) between 2013 and 2022. Data were collected using CMR reports, anaesthetic charts and medical records.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eFive-hundred twenty-two patients were in DS group and 171 in GA group. Most of the patients had congenital heart disease (86% in DS and 70% in GA group). There were overall 14 adverse events (2%); 8 (1.5%) in the DS group and 6 (3.5%) in GA group. This difference was not statistically significant (p\u0026thinsp;=\u0026thinsp;0.122). Complications in the DS group included mild anaphylactic reactions in 3 patients, a severe coughing fit in 1 patient, increasing cyanosis in 3 single ventricle patients and suspected aspiration in 1 patient. In the GA group, hypotension requiring some intervention was present in 3 patients(4 scans). One patient(0.6%) had inadvertent endobronchial intubation. One patient with unrepaired double outlet right ventricle and multilevel pulmonary stenosis experienced a severe cyanotic spell on induction to anaesthesia and the scan had to be abandoned.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eBoth DS and GA can be used for CMR scans in paediatric patients with a low rate of complications. This however requires highly skilled teams who adhere strongly to the safety policies and guidelines set up by each hospital.\u003c/p\u003e","manuscriptTitle":"Safety and feasibility of deep sedation and general anaesthesia for cardiovascular magnetic resonance imaging studies in paediatric patients from 2 large tertiary European centres","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-15 06:30:44","doi":"10.21203/rs.3.rs-7518455/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"02559c9c-b462-495b-9fd2-3198b2592204","owner":[],"postedDate":"September 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-21T06:53:08+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-15 06:30:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7518455","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7518455","identity":"rs-7518455","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}