A review of the complementary information available with cardiac magnetic resonance imaging and multi-slice computed tomography (CT) during the study of congenital heart disease

Cardiac Computed Tomography as a Diagnostic Modality for the Assessment of Complex Congenital Heart Disease Management

Here, we present a case of partial anomalous pulmonary venous return with the superior type of sinus venosus atrial septal defect. This case also had unusually persistent left-sided superior vena cava, which could not be diagnosed well in preoperative transthoracic echocardiography and required contrast-enhanced cardiac computed tomography scanning for proper diagnosing, operative planning, and avoidance of intraoperative problems. Postoperative, cardiac computed tomography scanning was also done to confirm adequate management.

Cardiac computed tomography angiography in the pre-operative assessment of congenital heart disease in Thailand

Introduction

Cardiac computed tomography angiography (CCTA) plays a vital role in clinical practice in evaluating patients with congenital heart disease (CHD) when the information from echocardiography is equivocal.

Aim

To test the hypothesis that CCTA has significantly value for pre-operative evaluation of congenital heart disease and practicality in the diagnosis and management of congenital heart disease patients at our tertiary care academic hospital.

Material and methods

We studied a total of 78 congenital heart disease patients (median age: 4.5 years) who had undergone CCTA during the period January 2017 to October 2018 at our tertiary care academic hospital.

Results

The results were classified as diagnostic categories, and the impact of the procedure on strategizing management was analysed. In each group, the CCTA offered an advantage and provided specific clues for surgical or interventional management. In total, the sensitivity (97.5%), specificity (100%), positive predictive value (100%), negative predictive value (99.38%), and accuracy (99.5%) of CCTA, for which the significant findings were confirmed by surgical or cardiac catheterization, were excellent, with average exposure per CCTA study calculated at 1.41 (0.36–3.28) mSv.

Conclusions

CCTA is an excellent non-invasive modality for the evaluation of congenital heart disease patients, with an important diagnostic and decision-aiding role.

Three-Dimensional Rotational Angiography during Catheterization of Congenital Heart Disease - A ten Years' experience at a single center

This paper aims to assess the usability and advantages of three-dimensional rotational angiography (3DRA) in patients with congenital heart disease (CHD) and its application in the cath lab. Up to now, its use in CHD is not widespread or standardized. We analyzed all patients with CHD who underwent a 3DRA at our facility between January 2010 and May 2019. The 3DRAs were evaluated for radiation exposure, contrast dye consumption, diagnostic utility and image quality. We performed 872 3DRAs. 3DRA was used in 67.1% of the cases for interventional procedures and in 32.9% for diagnostic purposes. Two different acquisition programs were applied. The median dose-area product (DAP) for all 872 rotations was 54.1 µGym² (21.7–147.5 µGym²) and 1.6 ml/kg (0.9–2.07 ml/kg) of contrast dye was used. Diagnostic utility of the generated 3D-model was rated superior to the native 3D angiography in 94% (819/872). 3DRA is an excellent and save diagnostic and interventional tool. However, 3DRA has not become a standard imaging procedure in pediatric cardiology up to now. Effort and advantage seems to be unbalanced, but new less invasive techniques may upgrade this method in future.

Three-dimensional rotational angiography in congenital heart disease: Present status and evolving future

Three-dimensional rotational angiography (3D-RA) enables volumetric imaging through rotation of the C-arm of an angiographic system and real-time 3D reconstruction during cardiac catheterization procedures. In the field of congenital heart disease (CHD), 3D-RA has gained considerable traction, owing to its capability for enhanced visualization of spatial relationships in complex cardiac morphologies and real time image guidance in an intricate interventional environment. This review provides an overview of the current applications, strengths, and limitations of 3D-RA acquisition in the management of CHD and potential future directions. In addition, issues of dosimetry, radiation exposure, and optimization strategies will be reviewed. Further implementation of 3D-RA will be driven by patient benefits relative to existing 3D imaging capabilities and fusion techniques balanced against radiation exposure.

3D modeling: a future of cardiovascular medicine

Cardiovascular disease resulting from atypical cardiac structures continues to be a leading health concern despite advancements in diagnostic imaging and surgical techniques. However, the ability to visualize spatial relationships using current technologies remains a challenge. Therefore, 3D modeling has gained significant interest to understand complex and atypical cardiovascular disorders. Moreover, 3D modeling can be personalized and patient-specific. 3D models have been demonstrated to aid surgical planning and simulation, enhance communication among surgeons and patients, optimize medical device design, and can be used as a potential teaching tool in medical schools. In this review, we discuss the key components needed to generate cardiac 3D models. We highlight prevalent structural conditions that have utilized 3D modeling in pre-operative planning. Furthermore, we discuss the current limitations of routine use of 3D models in the clinic as well as future directions for utilization of this technology in the cardiovascular field.

RV diastolic dysfunction: time to re-evaluate its importance in heart failure

Right ventricular (RV) diastolic dysfunction was first reported as an indicator for the assessment of ventricular dysfunction in heart failure a little over two decades ago. However, the underlying mechanisms and precise role of RV diastolic dysfunction in heart failure remain poorly described. Complexities in the structure and function of the RV make the detailed assessment of the contractile performance challenging when compared to its left ventricular (LV) counterpart. LV dysfunction is known to directly affect patient outcome in heart failure. As such, the focus has therefore been on LV function. Nevertheless, a strategy for the diagnosis and assessment of RV diastolic dysfunction has not been established. Here, we review the different causal mechanisms underlying RV diastolic dysfunction, summarising the current assessment techniques used in a clinical environment. Finally, we explore the role of load-independent indices of RV contractility, derived from the conductance technique, to fully interrogate the RV and expand our knowledge and understanding of RV diastolic dysfunction. Accurate assessment of RV contractility may yield further important prognostic information that will benefit patients with diastolic heart failure.

Korean guidelines for the appropriate use of cardiac CT

The development of cardiac CT has provided a non-invasive alternative to echocardiography, exercise electrocardiogram, and invasive angiography and cardiac CT continues to develop at an exponential speed even now. The appropriate use of cardiac CT may lead to improvements in the medical performances of physicians and can reduce medical costs which eventually contribute to better public health. However, until now, there has been no guideline regarding the appropriate use of cardiac CT in Korea. We intend to provide guidelines for the appropriate use of cardiac CT in heart diseases based on scientific data. The purpose of this guideline is to assist clinicians and other health professionals in the use of cardiac CT for diagnosis and treatment of heart diseases, especially in patients at high risk or suspected of heart disease.

Assessment of ductal blood flow in newborns with obstructive left heart lesions by cardiovascular magnetic resonance

BACKGROUND

Newborns with obstructive left heart lesions often depend on a patent ductus arteriosus to sustain the systemic circulation. Our aims were to validate the direct measurement of ductal flow, and to characterize the magnitude, determinants and hemodynamic effects of patent ductus arteriosus in newborns with obstructive left heart lesions by cardiovascular magnetic resonance (CMR).

METHODS

In this retrospective study, the CMR and clinical information of newborns with obstructive left heart lesions were reviewed. The feasibility and validity of measuring ductal flow and the correlations between ductal flow and ventricular volumes, ascending aortic flow, post-ductal oxygen saturation and Qp:Qs were assessed.

RESULTS

The CMR examinations of 32 newborns were included. It was possible to measure the ductal flow in all of them, with moderate-to-good agreement between measured and calculated ductal flow volume. The flow was bidirectional in all patients, with a net right-to-left shunt in 72%. Net ductal flow correlated inversely with ascending aortic flow (Rho -0.63; p 0.0002), post-ductal oxygen saturation (Rho -0.58; p 0.0004), Qp:Qs (Rho -0.43; p 0.02), and with left ventricular end-diastolic volume index (Rho -0.38; p 0.04). There was no correlation with the diameter of the ductus. The contribution of ductus flow to the systemic circulation correlated with the left ventricular end-diastolic volume index (Rho -0.47; p 0.02).

CONCLUSIONS

Direct measurement of ductal flow in newborns with obstructive left heart lesions is feasible. From these measurements, we were able to demonstrate that patients with smaller left ventricles and lower ascending aortic flow have a greater contribution of ductal flow to the systemic circulation. The size of the ductus arteriosus does not predict net ductal flow. Phase-contrast CMR can be an adjunct method for the assessment of the physiology for very ill neonate patients.

Infant cardiac CT angiography with 64-slice and 256-slice CT: comparison of radiation dose and image quality using a pediatric phantom

Background

The aims of this study were to investigate the image quality and radiation exposure of pediatric protocols for cardiac CT angiography (CTA) in infants under one year of age.

Methodology/Principal Findings

Cardiac CTA examinations were performed using an anthropomorphic phantom representing a 1-year-old child scanned with non-electrocardiogram-gated (NG), retrospectively electrocardiogram-gated helical (RGH) and prospectively electrocardiogram-gated axial (PGA) techniques in 64-slice and 256-slice CT scanners. The thermoluminescent dosimeters (TLD) were used for direct organ dose measurement, while dose-length product and effective mAs were also used to estimate the patient dose. For image quality, noise and signal-to-noise-ratio (SNR) were assessed based on regions-of-interest drawn on the reconstructed CT images, and were compared with the proposed cardiac image quantum index (CIQI). Estimated dose results were in accordant to the measured doses. The NG scan showed the best image quality in terms of noise and SNR. The PGA scan had better image quality than the RGH scan with 83.70% dose reduction. Noise and SNR were also corresponded to the proposed CIQI.

Conclusions/Significance

The PGA scan protocol was a good choice in balancing radiation exposure and image quality for infant cardiac CTA. We also suggested that the effective mAs and the CIQI were suitable in assessing the tradeoffs between radiation dose and image quality for cardiac CTA in infants. These results are useful for future implementation of dose reduction strategies in pediatric cardiac CTA protocols.

Impact of Preoperative 64-Slice CT Scanning on Mini-Maze Atrial Fibrillation Surgery

BACKGROUND

: Multidetector computed tomography (MDCT) is emerging as a powerful noninvasive diagnostic tool. The appropriate role of this technique in the preoperative evaluation of cardiovascular disease has yet to be fully defined. Atrial fibrillation is the most common sustained cardiac arrhythmia, and novel minimally invasive surgical techniques have been developed to treat this condition by electrically isolating the pulmonary veins. The ideal methodology to preoperatively evaluate these patients remains debatable. We hypothesized that 64-slice CT could significantly affect perioperative planning.

METHODS

: Thirty-six consecutive patients who consented to undergo minimally invasive pulmonary vein isolation at our institution underwent a preoperative 64-slice cardiac CT scan. All cardiac and noncardiac abnormalities were recorded, and modifications to the initial surgical plan were documented.

RESULTS

: The mean patient age was 64.4 ± 11.9 years [26 men (72.2%), 17 with known coronary artery disease (47.2%)]. Preoperative CT scanning detected 12 patients with abnormal pulmonary venous anatomy (33.3%), 3 with left atrial thrombus (8.3%), and 17 with significant coronary artery disease (47.2%). Furthermore, 20 studies (55.6%) detected pulmonary abnormalities (including 11 nodules). Preoperative scanning significantly altered surgical planning in 10 cases (27.8%). Alterations in patient treatment included preoperative invasive angiography, conversion of the mini-maze to an open chest procedure, alteration of surgical approach, and postponement/cancellation.

CONCLUSIONS

: Sixty-four-slice CT scanning is a safe, rapid, and accurate procedure with important ramifications for surgical planning. This methodology could become an alternative approach to screen preoperative cardiac surgical patients.

The fifth chamber of the heart: huge left atrial aneurysm

Cardiomegaly is a common but nonspecific finding in the emergency department. The etiology may be explained by left ventricular dilation, biventricular dilation, right ventricular dilation, or pericardial abnormalities, or it may be found to be spurious on the echocardiogram. Rarely, isolated abnormalities of the atrium, particularly the left atrium, may cause abnormalities on the chest radiograph but will not cause true cardiomegaly. We reported a 37-year-old woman who presented with persistent palpitation of a 6-hour duration. An electrocardiogram revealed atrial fibrillation with rapid ventricular response. A chest radiograph showed cardiomegaly with unusual prominence of the left heart border. A subsequent transthoracic echocardiography demonstrated an echo-free chamber adjacent to the left lateral wall of the left ventricle. The diagnosis of a rare huge left atrial aneurysm was finally established by multidetector-row computed tomography, which had been seldom used as a diagnostic tool in the past. Patients with this cardiac anomaly usually are asymptomatic until the second or third decade of life, when the aneurysms can reach remarkable sizes and are often complicated with atrial tachyarrhythmia or thromboembolic events. Early surgical intervention is advised even in asymptomatic patients to prevent the occurrence of myocardial dysfunction, atrial fibrillation, and systemic embolism.

The value of flat-detector computed tomography during catheterisation of congenital heart disease

OBJECTIVES

To analyse the diagnostic utility of flat-detector computed tomography imaging (FD-CT) in patients with congenital heart disease, including the value of image fusion to overlay three-dimensional (3D) reconstructions on fluoroscopic images during catheter-based interventions.

METHODS

We retrospectively analysed 62 consecutive paediatric patients in whom FD-CT was used during catheterisation of congenital heart disease. Expert operators rated the clinical value of FD-CT over conventional fluoroscopic imaging. Added radiation exposure and contrast medium volume were evaluated.

RESULTS

During a 12-month period, FD-CT was performed in 62 out of 303 cardiac catheterisations. Median patient age was 3.5 years. In 32/62 cases, FD-CT was used for diagnostic purposes, in 30/62 cases it was used in the context of interventions. Diagnostic utility was never rated as "misleading". It was classified as "not useful" in six cases (9.7%), "useful" in 18 cases (29.0%), "very useful" in 37 cases (59.7%) and "essential" in one case (1.6%). The median added dose-area product was 111.0 μGym(2), the required additional quantity of contrast medium was 1.6 ml/kg.

CONCLUSION

FD-CT provides useful diagnostic information in most of the patients investigated for congenital heart disease. The added radiation exposure and contrast medium volume are reasonable.

Role of multi-slice and three-dimensional computed tomography in delineating extracardiac vascular abnormalities in neonates

BACKGROUND

Recent advances in multi-slice computed tomography (MSCT) and three-dimensional computed tomography (3D CT) provide good-resolution images and short scan time for complete diagnosis of congenital heart disease (CHD). In the present study, we found that MSCT rapidly provides clinically relevant information for diagnosing extracardiac vascular anatomy in neonates with CHD. It is less invasive, necessitating only minimum or no sedation and a relatively small amount of contrast material. These advantages are crucial, especially for critically ill neonates.

METHODS

Between January 2007 and December 2008, MSCT scans were conducted on 41 neonates who were admitted to our neonatal intensive care unit. All the neonates were suspected to have complex CHD after an initial echocardiography examination. The scans were focused on detecting extracardiac vascular anatomy and abnormalities. All the image data sets were sent to image processing workstations for multiplanar interactive viewing and 3D reconstruction.

RESULTS

High-resolution MSCT scan images were obtained from 41 patients. Reported indications and findings of extracardiac abnormalities and related structural anatomy pertaining to congenital heart disease from MSCT and 3D CT findings were confirmed by clinical and surgical findings by a team of multidisciplinary congenital heart disease specialists.

CONCLUSION

Based on clinical and surgical confirmation of the MSCT scan results from a multidisciplinary congenital heart disease specialist team, we concluded that adequate information on CHD, specifically that regarding extracardiac abnormalities of the anatomy, can be obtained and MSCT can be used to replace cardiac catheterization.

Total anomalous pulmonary venous connection in an adult: comprehensive multimodality evaluation

An unusual case of total anomalous pulmonary venous connection surviving to adulthood without surgical correction is presented. Transthoracic echocardiography first led to this diagnosis and magnetic resonance imaging refined the anatomic diagnosis leading to successful surgical correction.

Cardiovascular magnetic resonance imaging for intensive care infants: safe and effective?

BACKGROUND

Cardiac magnetic resonance imaging (MRI) is an important diagnostic tool for congenital heart disease (CHD), as reflected by class 1 recommendations for the use of cardiac MRI by various consensus panels. However, little is known about the safety and clinical utility of cardiac MRI for these critically ill infants with CHD, whose further management cannot be directed by echocardiography. This study aimed to assess the safety, the potential hemodynamic side effects, and the clinical benefits of cardiac MRI for infants with complex CHD during their intensive care unit stay.

METHODS

Infants referred from the pediatric cardiac intensive care unit (PCICU) to the authors' cardiac MRI program in the past 2 years were retrospectively analyzed using the electronic chart system available at their institution. Data collected included age, diagnosis, inotropic support, urine output, diuretic medication, body temperature and lactate levels, length of MRI examination, adverse effects during and after the procedure, clinical implications of MRI, length of stay in the PCICU, and mean blood pressure and heart rate before, during, and after MRI.

RESULTS

Among 592 patients in the past 2 years, 20 (3.4%) were referred for MRI testing during their stay in the PCICU. The mean age of the infants was 4.8+/-3.2 months. Four of the patients were neonates, and eight were postoperative patients. Intracardiac malformations were present in 16 of the infants, vascular rings causing tracheal stenosis in 3 patients, and cardiomyopathy in 1 patient. The mean stay in the PCICU was 28+/-43 days. Eight of the infants were ventilated, with a mean fraction of inspired oxygen (FiO2) of 0.30+/-0.15. Four were receiving inotropic support. All the nonventilated children were intubated for the MRI and extubated in the MRI laboratory. The mean duration of the MRI (door-to-door time) was 110+/-27 min. All except one patient were hemodynamically stable, and no increase in catecholamine support was necessary during or after the scans. A 10-month-old girl receiving inotropic support needed a single dose of epinephrine due to a short episode of bradycardia after a breathhold for a contrast agent MRI angiography. Mean body core temperature at arrival to the PCICU was 36.8+/-0.7 degrees C. The mean serum lactate level after the MRI was 1.2+/-0.4 mmol/l. The mean blood pressure and heart rate before, during, and after MRI were unchanged. The mean diuresis on examination day was insignificantly lower (2.4%) than the day before with unchanged medication (5.09+/-1.58 vs 5.53+/-1.77 ml/kg/h). For 14 (70%) of the 20 patients, surgical or catheter interventional procedures were initiated based on novel MRI information.

CONCLUSION

Cardiac MRI can be performed safely with low risk and limited hemodynamic changes for infants during their stay in the PCICU. Cardiac MRI provides key information for invasive management decisions in this subset of patients.

64-slice multidetector-row computed tomographic angiography for evaluating congenital heart disease

This study aimed to assess critically the role of 64-slice multidetector-row computed tomographic (MDCT) angiography for evaluating congenital heart disease. The study enrolled 60 consecutive patients (median age, 4.7 years; median weight, 16.5 kg) with congenital heart disease who underwent 64-slice MDCT angiography during the period June 2006 through September 2007. The results were classified as diagnostic categories, and the impact of the procedure on strategizing management was critically analyzed. In each of the groups, the current technique offered a clear advantage over conventional imaging and provided specific clues for surgical/interventional management. A management algorithm was evolved based on questions frequently asked about pulmonary artery anatomy. The correlation with surgical anatomy in all cases that involved surgery was excellent. Early results suggest that 64-slice MDCT angiography is a major breakthrough in cardiovascular imaging with an important diagnostic and decision-aiding role. Diagnostic cardiac catheterization, especially for evaluating great vessel anomalies, could be largely replaced by the described technique for congenital heart disease.

How accurately, reproducibly, and efficiently can we measure left ventricular indices using M-mode, 2-dimensional, and 3-dimensional echocardiography in children?

BACKGROUND

Measurements of left ventricular (LV) size, mass, and function are the most common and important tasks for echocardiography in clinical practice and research in children with congenital and acquired heart diseases. There are little data to compare the utility of M-mode (MM), 2-dimensional (2D), and 3-dimensional (3D) echocardiographic techniques for quantification of LV indices. The objective of the study was to assess the accuracy, reproducibility, and efficiency of these echocardiographic methods for measurement of LV indices in children.

METHODS

A prospective study was conducted in 20 consecutive children (mean 10.6 +/- 2.8 years, 11 male and 9 female subjects) using conventional MM, 2D, and real-time 3D echocardiography (RT3DE). A Sonos 7500 system (Philips Medical Systems, Andover, MA) was used. M-mode and 2DE measurements were made according to the American Society of echocardiography recommendations. To include the entire LV for volumetric measurement, full-volume 3D data sets were acquired from 4 electrocardiogram gated subvolumes. The 3DE measurements were made off-line manually using 4-plane and 8-plane algorithms by 4D Echo-View (TomTec Imaging Systems, Munich, Germany) and a semiautomated algorithm by QLAB (Philips Medical Systems). Magnetic resonance imaging studies were also performed to determine the LV indices by a disk summation method based on the Simpson principle.

RESULTS

The correlation and agreement between MM, 2D, and RT3D echocardiography and magnetic resonance imaging measurements are good (r = 0.81-0.97) for the 3 methods. The correlation was superior for RT3DE compared with 2DE and MM. The correlation and agreement were similar for the three 3DE methods. The intra- and interobserver variabilities ranged from MM (4.3%-4.8% and 7.0%-8.7%), 2DE (3.3%-4.5% and 5.5%-7.3%), and 3DE (0.4%-2.3%, and 0.2%-4.8%). The total time (acquisition and analysis) used for MM measurements was the least compared with 2DE and 3DE. The total time for 3DE using the semiautomated algorithms was not significantly different compared with that for 2DE.

CONCLUSIONS

Our study showed that MM provides the most efficient assessment of LV indices but is the least accurate and reproducible technique compared with 2DE and 3DE. Three-dimensional echocardiography using both automated and manual analysis algorithm is superior to MM and 2DE for measurements of LV indices, and the automated 3DE algorithm is as efficient as 2DE. Therefore, 3DE using the automated algorithm is the method of choice for quantification of LV indices.

Delayed magnetic resonance imaging contrast enhancement of synthetic ventricular septum

This is a report of a magnetic resonance imaging with delayed contrast enhancement on an adult patient with double-inlet left ventricle and L-transposition of the great arteries who has undergone staged ventricular septation in childhood. This report is unique demonstration of delayed contrast enhancement of the synthetic Teflon septum.

Neonatal cardiac multidetector row CT: why and how we do it

Neonatal congenital heart disease is a most difficult area of diagnostic radiology because of the small patient body size and fast resting heart rate. Recently, the spatial and temporal resolution of multidetector-row CT (MDCT) has evolved so that neonatal congenital heart disease can be precisely diagnosed. We describe the role of MDCT in neonatal congenital heart disease and offer tips for the scanning procedure to familiarize radiologists with this developing field.

Appearance of noncompaction‐like remodeling of the anatomical right ventricle in a middle‐aged subject with modified transposition of the great arteries who did not undergo surgery

We describe noncompaction-like remodeling of the anatomical right ventricle (ARV) in a middle-aged subject with modified transposition of the great arteries (TGA). A 54 year-old male had been diagnosed with modified TGA at age 40, but no surgery was performed. Enhanced multislice CT revealed the ascending aorta coursing left of the anterior pulmonary trunk. Furthermore, the myocardium of the ARV appeared thickened, but contrast material could be observed in the ARV myocardium, which resembled noncompaction of the left ventricle (LV). We speculated trabecular development of the ARV, such as a Chiari network, and with TGA, the ARV provided systemic circulation through the aorta. The ARV wall may have thickened due to systemic pressure load, resulting in reduction of wall motion of the ARV on transthoracic echocardiogram. Recent advances in multislice CT imaging have revolutionized the exploration of RV anatomy, especially for depicting the three-dimensional appearance of noncompaction-like remodeling of the ARV in modified TGA in addition to transposition of the great arteries.

Role and effectiveness of cardiovascular magnetic resonance in the diagnosis, preoperative evaluation and follow-up of patients with congenital heart diseases

The substantial advances in the medical and surgical treatment of congenital heart diseases have dramatically improved patients' life expectancy, as well as increased the number of those needing lifelong monitoring to identify complications and residual defects. Magnetic resonance imaging (MRI) is an ideal imaging modality for the follow-up of these young patients owing to its noninvasiveness, high reproducibility and morphological and functional accuracy. This paper describes the most appropriate MRI techniques and sequences for the study of cardiovascular heart diseases on the basis of an analysis of MRI studies carried out between January 2003 and June 2006 on 274 patients affected by all of the main congenital cardiovascular malformations, as well as a review of the literature. The advantages of MRI with respect to other imaging techniques, the problems encountered and the main clinical applications and indications of MRI, with special reference to the most common disease entities, are then discussed to define the role, the utility and the future perspectives of this imaging technique in the study of congenital heart diseases.

Unique application of multislice computed tomography in adults with congenital heart disease

PURPOSE

Adults with congenital heart disease (CHD) form a growing population of patients requiring coronary artery assessment. In light of their increased incidence of coronary anomalies and need for reoperations, it is important to define their coronary anatomy. The purpose of this study was to define the spectrum of coronary artery anatomies and feasibility of coronary artery delineation in adults with CHD using 16- and 64-slice computed tomography angiography.

MATERIALS AND METHODS

Coronary multislice computed tomography (MSCT) examinations performed in adults with CHD between 2004 and 2005 were reviewed with institutional review board approval. Informed consent was not required. In addition to image quality, the following coronary parameters were evaluated by analysis of axial, multiplanar reformatted, and volume-rendered images: (1) relationship to great arteries, (2) ostia number and location, (3) proximal course, (4) length of vessel seen, and (5) dominance.

RESULTS

Eighty-five examinations in adults with CHD adults were identified. The relationship of the great vessels, number and location of the coronary ostia, and proximal course of the coronaries could be identified in all studies. Coronary anomalies were detected in 16 (19%) subjects. The entire coronary tree was visible in 77 (91%) of subjects.

CONCLUSIONS

MSCT provides detailed, noninvasive assessment of complex coronary artery anatomy in adults with CHD. MSCT should be considered a useful modality in the assessment of these patients, as it does not require arterial access and provides detailed 3-dimensional anatomic information that has important implications for long-term management.

Coronary anomalies by cardiac computed tomographic angiography

BACKGROUND

Early identification of an anomalous coronary anatomy is quite relevant because of the increased incidence of sudden cardiac death or related symptoms of myocardial ischemia in the patients. Invasive coronary angiography (ICA) is not only invasive, but expensive, and cannot always adequately provide the required information about the abnormal coronary anatomy. Cardiac computed tomographic angiography (CTA) is a robust noninvasive imaging modality that has several clinical applications and is now being used increasingly in practices across the nation. It not only provides high-resolution anatomical information of the coronary artery tree but also helps define other aspects of the cardiovascular anatomy, be it normal or abnormal.

HYPOTHESIS

This study sought to determine the clinical role played by CTA in the evaluation of different types of coronary arterial anomalies by reviewing CTA studies since 1997.

METHODS

We reviewed 6,089 case studies of contrast CTA conducted at our institution. There were 53 coronary anomalies in 39 patients (0.64%).

RESULTS

Computed tomographic angiography correctly identified the course of coronary arteries in all cases.

CONCLUSION

The results of this study support the use of CTA as a safe and effective noninvasive imaging modality for defining coronary arterial anomalies in an appropriate clinical setting, providing detailed three-dimensional anatomic information that may be difficult to obtain with invasive angiography.

Follow-up and physical activity in postoperative congenital heart disease

During the past three decades, interventional cardiology and cardiac surgery have found solutions even for the most complex congenital heart malformations with an overall low operative mortality. A careful clinical and instrumental follow-up of postoperative congenital heart disease patients is fundamental not only to prevent complications and/or to treat eventual residua and sequelae, but also to modify future surgical strategies on the basis of long-term results. To be able to give a correct prognostic meaning to the data collected during the follow-up, the cardiologist should have an excellent knowledge of the native defect, the surgical technique and the post-surgical anatomy and physiology. Major cardiological concerns during a follow-up after corrective surgery are: arrhythmias; heart failure; cyanosis and erythrocytosis; and infective endocarditis. Psychosocial needs, such as employment, contraception, pregnancy and physical exercise, are very important to enable a 'normal' life, complying with the postoperative hemodynamic situation of the patients.

Using multidetector-row CT in neonates with complex congenital heart disease to replace diagnostic cardiac catheterization for anatomical investigation: initial experiences in technical and clinical feasibility

BACKGROUND

Echocardiography is the first-line modality for the investigation of neonatal congenital heart disease. Diagnostic cardiac catheterization, which has a small but recognized risk, is usually performed if echocardiography fails to provide a confident evaluation of the lesions.

OBJECTIVE

To verify the technical and clinical feasibilities of replacing diagnostic cardiac catheterization with multidetector-row CT (MDCT) in neonatal complex congenital heart disease.

MATERIALS AND METHODS

Over a 1-year period we prospectively enrolled all neonates with complex congenital heart disease referred for diagnostic cardiac catheterization after initial assessment by echocardiography. MDCT was performed using a 40-detector-row CT scanner with dual syringe injection. A multidisciplinary congenital heart disease team evaluated the MDCT images and decided if further diagnostic cardiac catheterization was necessary. The accuracy of MDCT in detecting separate cardiovascular anomalies and bolus geometry of contrast enhancement were calculated.

RESULTS

A total of 14 neonates were included in the study. No further diagnostic cardiac catheterization was needed in any neonate. The accuracy of MDCT in diagnosing separate cardiovascular anomalies was 98% (53/54) with only one atrial septal defect missed in a patient with coarctation syndrome. The average cardiovascular enhancement in evaluated chambers was 471 HU. No obvious beam-hardening artefact was observed.

CONCLUSION

The technical and clinical feasibility of MDCT in complex congenital heart disease in neonates is confirmed. After initial assessment with echocardiography, MDCT could probably replace diagnostic cardiac catheterization for further anatomical clarification in neonates.

The right ventricle in congenital heart disease

In patients with congenital heart disease the right ventricle (RV) may support the pulmonary (subpulmonary RV) or the systemic circulation (systemic RV). During the last 50 years evidence is accumulating that RV dysfunction develops in many of these patients and leads to considerable morbidity and mortality. Therefore RV function in certain groups of congenital heart disease patients needs close surveillance and timely and appropriate intervention to optimise outcomes. Despite major progress being made, assessing the RV either in the subpulmonary or the systemic circulation remains challenging, often requiring a multi-imaging approach and expertise (echocardiography, magnetic resonance imaging, nuclear and occasionally invasive assessment with angiography). This review discusses the implications of volume and pressure loading of the RV in the context of congenital heart disease and describes the most relevant imaging modalities for monitoring RV function.

[Progress in pediatric cardiology and congenital heart defects]

We present a review of progress reported in the fields of pediatric cardiology and congenital heart disease between July 2004 and July 2005. The review covers diagnosis, medical treatment, interventional cardiology, and surgery. Among advances in diagnosis, we highlight new diagnostic imaging methods such as three-dimensional echocardiography, magnetic resonance imaging, CT angiography, and tissue Doppler imaging. In the area of fetal cardiology, we focus on advances in fetal interventions, such as percutaneous aortic valvuloplasty, percutaneous pulmonary valvuloplasty, and intact or restrictive atrial balloon septostomy. In interventional cardiology, we highlight advances in the application of percutaneous techniques to adult congenital heart disease to help solve problems resulting from previous surgery, and we review new devices for enabling the percutaneous closure of muscular and membranous ventricular septal defects. In cardiac surgery, a number of developments in valved conduits and in aortic translocation in patients with complex transposition of the great arteries are of particular interest.