Computed Tomography Angiography and Magnetic Resonance Angiography of Congenital Anomalies of Pulmonary Veins:

[Imaging of congenital heart defects with a focus on magnetic resonance imaging and computed tomography]

CLINICAL ISSUE

Due to advances in diagnostics and therapy, the survival rate of patients with congenital heart defects is continuously increasing. The aim of this review is to compare various imaging modalities that are used in the diagnosis of congenital heart defects.

METHODS

Transthoracic echocardiography is the imaging method of choice in the presence of a congenital heart defect because of its wide availability and non-invasiveness. It can be complemented by transesophageal echocardiography, cardiac catheterization, computed tomography (CT), and magnetic resonance imaging (MRI) of the heart and vessels close to the heart.

METHODICAL INNOVATIONS

The radiation exposure of CT examinations of the heart is continuously decreasing because of improved technologies. MRI is also being continuously optimized, e.g., by the acquisition of MR angiographies without contrast medium application or a thin three-dimensional (3D) visualization of the entire heart with the possibility of reconstruction in all spatial planes (whole-heart technique) as well as 2D to 4D flow.

PRACTICAL RECOMMENDATION

Due to the complexity of congenital heart defects and the variety of possible pathologies, the choice of imaging modality and its exact performance has to be coordinated in an interdisciplinary context and individually adapted.

Superior mesenteric artery revisited using magnetic resonance angiography

PURPOSE

We aimed to examine the superior mesenteric artery in detail by magnetic resonance angiography to provide an alternative to other imaging methods, to reduce the exposure time of patients and physicians to X-rays and the time spent in catheter angiography, to determine the variations, positions, and locations of the celiac trunk, and to provide detailed information for surgeons and interventional radiologists using this method.

METHODS

The procedures were approved by the Kocaeli University Medical School Non-Interventional Clinical Research Ethics Committee (10.04.2023, approval number: 2021/51). MR angiography images of 185 patients with abdominal imaging in PACS (Picture Archiving Communication Systems) were retrospectively registered. The level of origin of the superior mesenteric artery according to the vertebral column, angle of origin, distance between the superior mesenteric artery and branches of the abdominal aorta, and branching pattern of the superior mesenteric artery were evaluated. Parameters were evaluated according to gender and age using SPSS version 25.

RESULTS

The distance between superior mesenteric artery-inferior mesenteric artery and superior mesenteric artery-aortic bifurcation in males was higher than in females, and the difference was statistically significant. In females and the whole study group, a low, positive and significant relationship was found between age and superior mesenteric artery-sagittal angle. The most common origin site for the superior mesenteric artery, according to the vertebral column was found to be at L1 middle for males and L1 upper for females. The most common superior mesenteric artery branching pattern was classical type in both genders.

CONCLUSION

Individual evaluation of the superior mesenteric artery could reduce the risks during surgical interventions, considering the relationship of the superior mesenteric artery, especially with distally located vessels, and the gender differences for the angle of origin. Furthermore, considering that interventional radiologists choose the catheter according to the angle of origin of the artery during catheter angiography procedures, individual evaluation of patients taking into account gender and age is of utmost importance.

Multidetector Computed Tomography (MDCT) Angiography Evaluation of Total Anomalous Pulmonary Venous Connection

Total anomalous pulmonary venous connection (TAPVC) is a rare congenital cardiovascular malformation in which all four pulmonary veins anomalously drain into the right atrium (RA) either directly or indirectly. There are four main types based on the site of connection. Any type of TAPVC may be associated with obstruction and presents early in the neonatal period with cyanosis, tachycardia, or respiratory distress. We present four cases of all types of TAPVC and its imaging findings in multidetector computed tomography (MDCT) angiography. Cardiac CT and magnetic resonance imaging (MRI) are very useful in delineating the anatomy and drainage pathway of anomalous pulmonary veins. MDCT angiography is noninvasive and easily available, and rapid image acquisition is possible with high spatial resolution. Since early diagnosis and surgical correction are necessary for the survival of these neonates, rapid image acquisition using MDCT angiography can be preferred over MRI.

Case report: A unique quadruple coexisting anomaly-scimitar syndrome, atrial septal defect, vascular ring, and pulmonary sequestration

The article describes a successful clinical outcome in the case of a 5-month old female with a diagnosis of incomplete vascular ring of aberrant right subclavian artery and ostium secundum atrial septal defect associated with partial anomalous pulmonary venous return of scimitar syndrome type, coexisting with right pulmonary sequestration. During hospitalization, surgical correction of the heart defect and resection of the lung sequestration were performed. To the best of our knowledge, described constellation of defects is a unique phenomenon, posing a challenge for complex treatment and disease management.

Computed tomography and magnetic resonance imaging of congenital thoracic systemic venous anomalies

We present the imaging findings of thoracic systemic venous anomalies diagnosed by computed tomography and magnetic resonance imaging. Persistent left superior vena cava is the commonest anomaly of the thoracic systemic veins encountered either incidentally as an isolated finding or associated with congenital heart disease. Inferior vena cava (IVC) interruption with azygos continuation is the second most common anomaly, which may also be isolated or be associated with left isomerism syndrome. The article will also discuss other rarer systemic venous anomalies including retroaortic brachiocephalic vein and IVC drainage into the left atrium. Finally, the impact of pre-procedure reporting of thoracic systemic venous anomalies on the choice of intervention and patient outcome will be addressed.

Multimodality imaging in delineation of complex sinus venosus defects and treatment outcomes over the last decade

BACKGROUND

Diagnosis of sinus venosus defects, not infrequently associated with complex anomalous pulmonary venous drainage, may be delayed requiring multimodality imaging.

METHODS

Retrospective review of all patients from February 2008 to January 2019.

RESULTS

Thirty-seven children were diagnosed at a median age of 4.2 years (range 0.5-15.5 years). In 32 of 37 (86%) patients, diagnosis was achieved on transthoracic echocardiography, but five patients (14%) had complex variants (four had high insertion of anomalous vein into the superior caval vein and three had multiple anomalous veins draining to different sites, two of whom had drainage of one vein into the high superior caval vein). In these five patients, the final diagnosis was achieved by multimodality imaging and intra-operative findings. The median age at surgery was 5.2 years (range 1.6-15.8 years). Thirty-one patients underwent double patch repair, four patients a Warden repair, and two patients a single-patch repair. Of the four Warden repairs, two patients had a high insertion of right-sided anomalous pulmonary vein into the superior caval vein, one patient had bilateral superior caval veins, and one patient had right lower pulmonary vein insertion into the right atrium/superior caval vein junction. There was no post-operative mortality, reoperation, residual shunt or pulmonary venous obstruction. One patient developed superior caval vein obstruction and one patient developed atrial flutter.

CONCLUSION

Complementary cardiac imaging modalities improve diagnosis of complex sinus venosus defects associated with a wide variation in the pattern of anomalous pulmonary venous connection. Nonetheless, surgical treatment is associated with excellent outcomes.

Coexistence of Cor Triatriatum Sinister, Fibroelastoma and Pulmonary Veins Ostial Anatomy Variant as Incidental Findings in Coronary Computed Tomography Angiography

Coronary computed tomography angiography (CCTA) is a noninvasive examination whose main purpose is to exclude significant stenosis in the coronary arteries. The obtained computed tomography images may also provide information about other coexisting pathologies of the heart and vessels. The paper presents images of cardiac lesions in a 44-year-old hypertensive patient who underwent CCTA, based on which significant stenosis in the coronary arteries was excluded, the suspicion of a cor triatriatum sinister was confirmed and the presence of fibroelastoma and a variant of the anatomy of the pulmonary veins ostial was confirmed. To sum up, when performing CCTA, apart from the analysis of the coronary arteries, one should remember about lesions in the remaining visible anatomical structures of the heart and large vessels.

Essential role of cardiac computed tomography for surgical decision making in children with total anomalous pulmonary venous connection and single ventricle

BACKGROUND

Total anomalous pulmonary venous connection (TAPVC) is a major risk factor in infants with single ventricle (SV). Exact definition of TAPVC anatomy is crucial for surgical planning.

AIM

To evaluate the role of cardiac computed tomography (CT) in this setting.

METHODS

Retrospective review of 13 infants who underwent TAPVC repair associated with SV from May 2016 to October 2021. Anatomy, incidence, and mechanisms of pulmonary venous obstruction (PVO) were described. Cardiac CT diagnostic yield was compared to echocardiography (echo).

RESULTS

Of 13 infants, median age and weight were 24 days (range 2-303 days) and 3.2 (range 2.6-9.1) kg, 8 (62%) were male, 4 (31%) premature, and 11 (85%) had heterotaxy syndrome. All infants had pre- and postoperative echo; 13 had preoperative and 8 (62%) had postoperative cardiac CT. Type of TAPVC: six (46%) supracardiac, two (15%) intracardiac, one (8%) infracardiac, and four (31%) mixed, with pulmonary veins draining in >1 confluence in nine (69%). PVO was present in 6/13 (46%) preoperatively and 5/13 (31%) postoperatively. Mechanisms of PVO: 9/11 (82%) stenosis, 1/9 (9%) membrane formation, and 1/9 (9%) external compression. The sensitivity to diagnose PVO was 45.5% for echo and 100% for cardiac CT, the specificity was 100% for both. No discrepancy was found between cardiac CT and intraoperative findings, but echo had a complete preoperative diagnosis in 1/13 (8%) (p < .00001, Fisher exact test).

CONCLUSIONS

Cardiac CT is essential to evaluate pre- and postoperative TAPVC in SV for surgical decision making and long term follow up.

Pleuropulmonary MDCT Findings: Comparison between Children with Pulmonary Vein Stenosis and Prematurity-Related Lung Disease

Purpose: To retrospectively compare the pleuropulmonary MDCT findings in children with pulmonary vein stenosis (PVS) and prematurity-related lung disease (PLD). Materials and Methods: All consecutive infants and young children (≤18 years old) who underwent thoracic MDCT studies from July 2004 to November 2021 were categorized into two groups—children with PVS (Group 1) and children with PLD without PVS (Group 2). Two pediatric radiologists independently evaluated thoracic MDCT studies for the presence of pleuropulmonary abnormalities as follows—(1) in the lung (ground-glass opacity (GGO), triangular/linear plaque-like opacity (TLO), consolidation, nodule, mass, cyst(s), interlobular septal thickening, and fibrosis); (2) in the airway (bronchial wall thickening and bronchiectasis); and (3) in the pleura (thickening, effusion, and pneumothorax). Interobserver agreement between the two reviewers was evaluated with the Kappa statistic. Results: There were a total of 103 pediatric patients (60 males (58.3%) and 43 females (41.7%); mean age, 1.7 years; range, 2 days−7 years). Among these 103 patients, 49 patients (47.6%) comprised Group 1 and the remaining 54 patients (52.4%) comprised Group 2. In Group 1, the observed pleuropulmonary MDCT abnormalities were—pleural thickening (44/49; 90%), GGO (39/49; 80%), septal thickening (39/49; 80%), consolidation (4/49; 8%), and pleural effusion (1/49; 2%). The pleuropulmonary MDCT abnormalities seen in Group 2 were—GGO (45/54; 83%), TLO (43/54; 80%), bronchial wall thickening (33/54; 61%), bronchiectasis (30/54; 56%), cyst(s) (5/54; 9%), pleural thickening (2/54; 4%), and pleural effusion (2/54; 4%). Septal thickening and pleural thickening were significantly more common in pediatric patients with PVS (Group 1) (p < 0.001). TLO, bronchial wall thickening, and bronchiectasis were significantly more frequent in pediatric patients with PLD without PVS (Group 2) (p < 0.001). There was high interobserver kappa agreement between the two independent reviewers for detecting pleuropulmonary abnormalities on thoracic MDCT angiography studies (k = 0.99). Conclusion: Pleuropulmonary abnormalities seen on thoracic MDCT can be helpful for distinguishing PVS from PLD in children. Specifically, the presence of septal thickening and pleural thickening raises the possibility of PVS, whereas the presence of TLO, bronchial wall thickening and bronchiectasis suggests PLD in the pediatric population.

Investigation of the correlation between cardiac parameters and aortic diameter in patients with ascending aortic aneurysm

Background

Aortic aneurysms (AA) are enlargement of the aorta silently until diagnosing, not detectable on physical examination, and usually incidentally discovered during radiologic scanning for other reasons. It can get bigger sizes and can result in life-threatening outcomes if not detected early on. In this study, we aimed to determine the relationship between ascending aortic diameter and cardiac parameters that can be detected with tomography or/and echocardiography. Newly diagnosed (n: 85) ascending AA patients and healthy individuals (n: 86) who have not any thoracic pathology in computed tomography (CT) scans included to the study. Echocardiographically determined left atrial dimension (LAD), left ventricular end-diastolic diameter (LVDd), left ventricular end-systolic diameter (LVDs), left ventricular ejection fraction (LVEF) and the left ventricular posterior wall thickness (LVPWd) values of each patient were recorded. The thorax diameters, ascending aorta diameters and cardiac volume values recorded from CT scans. The obtained findings were statistically compared.

Results

Positive correlation was found between aortic diameter and aging (p: 0.000). Increased thorax diameter and cardiac volume values were detected in ascending AA cases (p < 0.05). It was found to be ascending aortic diameter was positively correlated with thorax diameter and cardiac volume (0.50 < r ≤ 0.70) values and higher aortic diameter, cardiac volume, thorax diameter values were detected in male individuals when compared with the female gender. There was no significant correlation between LVEF, LVDd, and LVDs values and aortic diameter.

Conclusions

Cardiac volume and thorax diameter were found as strongly correlated with the diameter of the ascending aorta. The clarifying of these parameters with larger cohorts might be beneficial for the estimation of the progression of ascending AA.

Imaging of peripheral vascular malformations - current concepts and future perspectives

Vascular Malformations belong to the spectrum of orphan diseases and can involve all segments of the vascular tree: arteries, capillaries, and veins, and similarly the lymphatic vasculature. The classification according to the International Society for the Study of Vascular Anomalies (ISSVA) is of major importance to guide proper treatment. Imaging plays a crucial role to classify vascular malformations according to their dominant vessel type, anatomical extension, and flow pattern. Several imaging concepts including color-coded Duplex ultrasound/contrast-enhanced ultrasound (CDUS/CEUS), 4D computed tomography angiography (CTA), magnetic resonance imaging (MRI) including dynamic contrast-enhanced MR-angiography (DCE-MRA), and conventional arterial and venous angiography are established in the current clinical routine. Besides the very heterogenous phenotypes of vascular malformations, molecular and genetic profiling has recently offered an advanced understanding of the pathogenesis and progression of these lesions. As distinct molecular subtypes may be suitable for targeted therapies, capturing certain patterns by means of molecular imaging could enhance non-invasive diagnostics of vascular malformations. This review provides an overview of subtype-specific imaging and established imaging modalities, as well as future perspectives of novel functional and molecular imaging approaches. We highlight recent pioneering imaging studies including thermography, positron emission tomography (PET), and multispectral optoacoustic tomography (MSOT), which have successfully targeted specific biomarkers of vascular malformations.

Coronary artery disease imaging reporting and data system (CAD-RADS): what radiologists need to know?

The aim of this work is to review Coronary Artery Disease Imaging Reporting and Data System (CAD-RADS) that was designed to standardize reporting language and improve the communication of data among radiologists and clinicians. Stenotic lesions are graded into 5 grades ranging from 0 (no stenosis) to 5 (total occlusion), where the highest grade represents the final score. The expert consensus platform has added 4 special modifiers (non-diagnostic, stent, graft, and vulnerability) to aid patient management through linking these scores with decision algorithm and treatment plan. Adherence to standard imaging protocol; knowledge of normal, variant, and anomalous anatomy; and skillful evaluation of stenosis are important for proper utilization of this reporting system. Lastly, radiologists should be aware of the inherited benefits, limitations, and common pitfalls of this classification system.

Cor triatriatum with supramitral ring: "cor tetratriatum", associated with Raghib syndrome with Eisenmenger syndrome: multimodality imaging approach in this exceedingly rare case report

Background

Cor triatriatum and supramitral ring are congenital anomalies which result in formation of three chambers of atria. To the best of our knowledge, simultaneous presence of both entities in the same patient resulting in the formation of four chambers of atria has not been described in the literature. Here, we report a case of simultaneous presence of cor triatriatum and supramitral ring associated with Raghib syndrome and Eisenmenger syndrome.

Case presentation

We report the case of a middle-aged gentleman, who presented to us with features of atrial septal defect with Eisenmenger syndrome. Multimodality imaging confirmed the simultaneous presence of supramital ring and cor triatriatum resulting in “cor tetratriatum” along with Raghib syndrome. Presence of Eisenmenger syndrome compelled us to offer medical therapy for the patient.

Conclusion

This is the first case report describing the simultaneous presence of supramitral ring and cor triatriatum resulting in a new entity—“cor tetratriatum”.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43044-021-00183-4.

Multi-Modality Imaging Approach in a Challenging Case of Surgically Corrected Partial Anomalous Pulmonary Venous Return and Atrial Tachycardia Treated With Radiofrequency Ablation

Pulmonary anomalous venous return (PAPVR) is defined as a congenital anomaly in which at least one but not all of the pulmonary veins abnormally drain into a systemic vein or directly into the right atrium. Signs and symptoms related to this condition are due to the hemodynamic abnormalities secondary to left-to-right shunt and the possible presence of other associated cardiac anomalies (e.g., sinus venous atrial septal defect). Therefore, depending on the extent of the shunt, the clinical presentation of PAPVR is variable, ranging from asymptomatic patients to patients affected by severe heart failure with right-sided volume overload. PAPVR with a clinically significant shunt should be referred for surgical correction with different techniques depending on the presence of associated cardiac anomalies.

We are presenting a case of partial anomalous venous return (PAPVR) in a 66-year-old man who underwent surgery 26 years ago to correct an anomalous venous connection between the right superior pulmonary vein (RSPV) and the superior vena cava (SVC) through a veno-atrial baffle. The patient was admitted to the emergency department due to atrial tachycardia. Trans-thoracic echocardiography (TTE) showed a dilated right ventricle (RV) with mild RV systolic dysfunction and pulmonary hypertension. Cardiac magnetic resonance (CMR) further confirmed the findings described by TTE and also demonstrated areas of fibrosis replacement in the hinge points. Cardiac computed tomography (CCT) was able to accurately depict and evaluate the surgically created veno-atrial baffle and also showed an anomalous connection between the left superior pulmonary vein (LSPV) and the brachiocephalic vein (BCV) through a vertical vein. The patient was successfully treated with radiofrequency ablation for his arrhythmia.

Further Improving Image Quality of Cardiovascular Computed Tomography Angiography for Children With High Heart Rates Using Second-Generation Motion Correction Algorithm

BACKGROUND

The state-of-art motion correction algorithm is inadequate for correcting motion artifacts in coronary arteries in cardiovascular computed tomography angiography (CCTA) for children with high heart rates, and even less effective for heart structures beyond coronary arteries.

PURPOSE

This study aimed to evaluate the effectiveness of a second-generation, whole-heart motion correction algorithm in improving the heart image quality of CCTA for children with high heart rates.

MATERIALS AND METHODS

Forty-two consecutive symptomatic cardiac patients with high heart rates (122.6 ± 18.8 beats/min) were enrolled. All patients underwent CCTA on a 256-row CT using a prospective electrocardiogram-triggered single-beat protocol. Images were reconstructed using a standard algorithm (STD), state-of-the-art first-generation coronary artery motion correction algorithm (MC1), and second-generation, whole-heart motion correction algorithm (MC2). The image quality of the origin of left coronary, right coronary, aortic valve, pulmonary valve, mitral valve, tricuspid valve, aorta root, pulmonary artery root, ventricular septum (VS), and atrial septum (AS) was assessed by 2 experienced radiologists using a 4-point scale (1, nondiagnostic; 2, detectable; 3, measurable; and 4, excellent); nonparametric test was used to analyze and compare the differences among 3 groups; and post hoc multiple comparisons were used between different methods.

RESULTS

There were group differences for cardiac structures except VS and AS, with MC2 having the best image quality and STD having the worst image quality. Post hoc multiple comparisons showed that MC2 was better than MC1 and STD in all structures except VS and AS where all 3 algorithms performed equally, whereas MC1 was better than STD only in the origin of left coronary, right coronary, and mitral valve.

CONCLUSIONS

A second-generation, whole-heart motion correction algorithm further significantly improves cardiac image quality beyond the coronaries in CCTA for pediatric patients with high heart rates.

Imaging of Pulmonary Atresia With Ventricular Septal Defect

The aim of this article was to review computed tomography angiography and magnetic resonance angiography of pulmonary atresia with ventricular septal defect. This disorder is a rare complex congenital heart disease. Preoperative imaging of pulmonary atresia with ventricular septal defect with computed tomography angiography and magnetic resonance angiography is important for complete anatomical delineation and planning for treatment. Preoperative imaging used for assessment of the main pulmonary artery (its size, valve, and confluence), aortopulmonary collaterals (its origin, insertion, course, and size), presence of patent ductus arteriosus, other sources of collaterals as bronchial and coronary arteries, and pattern of pulmonary arborization. Imaging can detect associated aortic, pulmonary venous and coronary anomalies, and other congenital heart disease. Postoperative imaging after unifocalization and stent is for assessment of patency, stenosis, and occlusion of stent or perivascular lesions as seroma.