cardiac ct and mri in congenital heart disease (2) · cardiac ct and mri in congenital heart...
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Pediatrics
Cory V. Noel, M.D.Assistant Professor – Medical Director CMRPediatric Cardiology
Cardiac CT and MRI in Congenital Heart Disease
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No Disclosures
• Thanks to Prakash Masand for CT images
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• Common scenarios where CT and MRI are utilized
• How does CT and MRI add value in these patients
Outline
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Trends in Cardiovascular CT/MR Imaging
3 620
36 4048
56 6068 70
4550 52 55
4858 56 54 56
62
4856
72
91 88
106112 114
124132
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Imaging Trendsat Texas Children's Hospital
CT MRI Total Studies
Data per month
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MRI CTIntracardiac anatomy, flow, function and viability imagingComprehensive evaluation of extracardiac anatomy (heterotaxy, entire aorta)Definition of small vessels and higher order branchesEmergent evaluation (especially neonates and infants)
Airway, and lung parenchyma
.
CT versus MRI Choice
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• Tremendous growth in Computed Tomography (CT) imaging
-Fast scan times (0.27 to 0.35 seconds)
-Excellent resolution (0.5 mm)
-Physiologic information
-3-D post processing
CT Background
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• Complimentary to Echocardiography
• Fast acquisition with consistent results
• Excellent modality for emergent indications
• No sedation required
• Motion correction & Artifact reduction tools
Advantages: CT
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• Complex anatomy in neonates & infants
• Coronary arteries
• Adult congenital heart disease with single targeted question
• Dynamic imaging
Common Clinical Indications
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Evaluation of Pulmonary Arteries
• 2 day old for evaluation of branch pulmonary arteries
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• Total anomalous pulmonary venous connection –Infracardiac type
Evaluation of Pulmonary Veins
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Aortic Arch Assessment
• Severe aortic coarctation with
tubular arch hypoplasia
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Vascular Ring Investigation
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Post Infantile Surgical Assessment
• Occluded Blalock TaussigThomas shunt (BTT shunt)
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Stage 1 Norwood: Sano shunt
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Vascular stent
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Coronary Artery Assessment
• Coronary ostial stenosis
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Virtual Angioscop
y
Coronary Artery Assessment
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Coronary Artery Assessment
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ACHD - RV-PA Conduit
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ACHD - Ross procedure
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ACHD – Atrial Baffle
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Multiparametric Nature of Cardiac MRI
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TOF Predictors of Outcome
Geva T, JCMR, 2011
Hemodynamic Sequelae
HistoryElectrophysiological Markers
• Prolonged QRS• Sustained VT
• RV Dilation• Ventricular
dysfunction• Regional wall motion
abnormalities
• Syncope• Older age at
repair
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Impact of Pulmonary Regurgitation
Geva T, JCMR, 2011
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Post-Operative Echocardiogram
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Echocardiography versus CMR
Margossian R, et al., Amer J of Cardiol, 2009
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Post-Operative CMR
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Geva T, JCMR, 2011
Oosterhof T, Circulation, 2007
Therrien J, Amer J of Cardio., 2005
Study RVEDVi RVESVi RV/LV RV EF LV EF RVOTO BPA Stenosis
Geva T, et
al>150 mL >80 mL >2 <47% <55%
>2/3rd
Systemic
>70:30%
difference
Oosterhof
T, et al>160 mL >82 mL <45%
Therrien,
J, et al>170 mL >85 mL
Knauth
AL, et alZ-score >7
Knauth AL, Heart, 2006
Pulmonary Valve Replacement
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• Unilateral or bilateral branch pulmonary artery stenosis is a common complication
- Maskatia, et al., 178 patients reviewed with 11% having bilateral stenosis, 26% unilateral stenosis
- Harris, et al., 76 patients reviewed with 39% having either bilateral or unilateral stenosis
Branch Pulmonary Artery Stenosis
Maskatia S, et al., Amer J of Cardio., 2013Harris MA, et al., JACC Imaging, 2011
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Branch Pulmonary Artery Stenosis
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Branch Pulmonary Artery Stenosis
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Rapid Progression of RV Dysfunction
Wald R, et al., Heart, 2015Shin YR, et al., Euro J of CT Surgery, 2016
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Protocol• Axial Black Blood
• Cine imaging- VLA
- 4 Chamber
- SAX
- RVOT
- Branch PA’s
• Flow Quantification- Aorta
- MPA
- RPA / LPA
- AVV
• 3D Whole Heart
• MRA
• Optional- Delayed enhancement if adult, history of depressed function or arrhythmia
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• Second most common cyanotic heart lesion with incidence of approximately 30 / 100k live births
- Approximate 5-7% of all CHD defects
• Approximately 40-45% have a VSD (Complex TGA)
- Over half of these with concomitant LVOT obstruction
• Rare associated lesions include arch anomalies and pulmonary venous return abnormalities
D-TGA
Haeffele C, et al., Cardiol. Clinic, 2015Villafane, et al., JACC, 2014d
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• Majority survive to adulthood
- Survival at 15 years ~ 88%
• Freedom from reintervention is 82% at 15 years
- Reoperation < 10%
Arterial Switch Operation
Haeffele C, et al., Cardiol. Clinic, 2015Villafane, et al., JACC, 2014d
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• Initial ASO mortality quite high due to coronary ischemia
• Incidence of myocardial ischemia is most prevalent in first 3 months
- Bimodal pattern of incidence
• Coronary obstruction present in 5% - 7% of ASO survivors
Coronary Ischemia
Haeffele C, et al., Cardiol. Clinic, 2015Villafane, et al., JACC, 2014d
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Coronary Ischemia After ASO
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Protocol• Axial Black Blood
• Cine imaging- VLA- 4 Chamber
- SAX- RVOT- Branch PA’s
• Flow Quantification- Aorta- MPA- RPA / LPA- AVV
• 3D Whole Heart
• MRA
• Delayed Enhancement
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Fontan
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Decrease Exercise
Tolerance
Complications of
Fontan Palliation
Atrial and Ventricular Arrhythmia
Anderson, PA et al., JACC, 2008
Ventricular Systolic
Dysfunction
Ventricular Diastolic
Dysfunction
AV andSemilunar
Valve
A-P and Veno-venous
Collaterals
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Significance of Ventricular Dilation
Ghelani S, et al., American J of Cardiology, 2015
Indexed volume > 125 mL
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Significance of Ventricular Dilation
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• Reliance upon unobstructed branch pulmonary arteries
• May be difficult to detect by echo
Pulmonary Arteries
Krupickova , S et al., Euro Heart Journal, 2016
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• Multiple methods to quantify collateral flow
A-P Collateral Quantification
Whitehead K, et al., American J of Cardiology, 2015
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A-P Collateral
Grosse-Wortman L, et al., Circulation: CV Imaging, 2008
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Thrombus Evaluation
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Ventricular Fibrosis
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Protocol• Gadovist with LOWER EXTREMITY IV
• Axial and Coronal Black Blood
• Cine- VLA- 4-Chamber- SAX- Axial Branch PA’s- Coronal PA’s- Aortic Arch
• Flow Quantification
• MRA
• Delayed Enhancement
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Hypertrophic Cardiomyopathy
HCM
Fibrosis
Disarray
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Diagnosis & Management
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Diagnosis & Management
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• Thickness of interventricular septum greater than 30 mm is independent risk factor
• Presence of delayed enhancement associated with arrhythmia and 7 fold increase in adverse outcomes
Risk Stratification in HCM
Maron M, et al., JCMR, 2012Chan, et al., Circulation, 2014Rowin E, Diag. Ablation & Physio., 2016
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Protocol• Axial Black Blood
• Cine imaging- VLA- 4 Chamber- SAX- LVOT
• Flow Quantification- Aorta- MPA- AVV
• 3D Whole Heart
• MRA
• Delayed Enhancement
• Mapping Sequences
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Lake Louis Criteria
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• Lake Louise criteria comprised of increased signal on T2-weighted images, EGE ratio, and LGE
Lake Louis Criteria
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• 13 centers, 143 patients, clinical diagnosis
- LGE: 100% Abnormal in 81%
- T2w: 69% Abnormal in 74%
- EGE: 28% Abnormal in 55%
- FPP: 48% Abnormal in 8%
• LV EDV, LVEF, RVEF predictive of persistent dysfunction
Lake Louise Criteria
Banka P, et al., JCMR, 2015
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Diagnosis & Management
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• Does MRI have a predictive role in recently diagnosed DCM
• Myocardial inflammation on CMR is a strong predictor of LV recovery
- 66 children within 2 weeks of DCM diagnosis
- In 33/66, CMR identified at least one criterion of inflammation
Myocarditis vs. DCM
Raimondi F, Euro Heart Journal, 2015
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Diagnosis & Management
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Diagnosis & Management
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CMR in All Myocarditis?
Maron B, et al., Circulation, 2015
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CMR in All Myocarditis?
Maron B, et al., Circulation, 2015
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CMR in All Myocarditis?
Maron B, et al., Circulation, 2015
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• ACHD is a growing population• Pulmonary Hypertension• Interventional CMR• Hematology & Oncology
Additional Directions
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• Cardiac CT allows rapid acquisition with typically low radiation doses and excellent spatial resolution
• Cardiac MRI has many strengths that extend beyond ventricular volume and function
• Myocardial characterization techniques are demonstrating value in non-CHD
Take-Home Points
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Thank you….• Cardiovascular Imaging team
• CT/MRI technologists and nursing
• Radiology colleagues