Imaging in Adult Congenital Heart Disease

ACR Appropriateness Criteria® Congenital or Acquired Heart Disease

Pediatric heart disease is a large and diverse field with an overall prevalence estimated at 6 to 13 per 1,000 live births. This document discusses appropriateness of advanced imaging for a broad range of variants. Diseases covered include tetralogy of Fallot, transposition of great arteries, congenital or acquired pediatric coronary artery abnormality, single ventricle, aortopathy, anomalous pulmonary venous return, aortopathy and aortic coarctation, with indications for advanced imaging spanning the entire natural history of the disease in children and adults, including initial diagnosis, treatment planning, treatment monitoring, and early detection of complications. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

A Comprehensive Updated Review on Magnetic Nanoparticles in Diagnostics

Magnetic nanoparticles (MNPs) have been studied for diagnostic purposes for decades. Their high surface-to-volume ratio, dispersibility, ability to interact with various molecules and superparamagnetic properties are at the core of what makes MNPs so promising. They have been applied in a multitude of areas in medicine, particularly Magnetic Resonance Imaging (MRI). Iron oxide nanoparticles (IONPs) are the most well-accepted based on their excellent superparamagnetic properties and low toxicity. Nevertheless, IONPs are facing many challenges that make their entry into the market difficult. To overcome these challenges, research has focused on developing MNPs with better safety profiles and enhanced magnetic properties. One particularly important strategy includes doping MNPs (particularly IONPs) with other metallic elements, such as cobalt (Co) and manganese (Mn), to reduce the iron (Fe) content released into the body resulting in the creation of multimodal nanoparticles with unique properties. Another approach includes the development of MNPs using other metals besides Fe, that possess great magnetic or other imaging properties. The future of this field seems to be the production of MNPs which can be used as multipurpose platforms that can combine different uses of MRI or different imaging techniques to design more effective and complete diagnostic tests.

Late gadolinium enhancement in patients with Tetralogy of Fallot: A systematic review

PURPOSE

The aim of this study is to review the literature concerning myocardial late gadolinium enhancement (LGE) with cardiac magnetic resonance in patients with Tetralogy of Fallot (ToF), with regards to its prevalence, characteristics and clinical relevance.

METHODS

We performed a systematic search, aiming to retrieve original articles that evaluated LGE in ToF, running a search string on MEDLINE and EMBASE in November 2019 and November 2020. Papers were then selected by two independent, blinded readers based on title and abstract, and then on full-text reading, and articles which did not include LGE evaluation were excluded. From each included paper two readers extracted descriptive data concerning technical parameters of LGE acquisition, LGE description and clinical significance.

RESULTS

18 articles were eventually included in our review. The included studies observed that a higher amount of right ventricular LGE relates with higher right ventricular volumes, lower ejection fraction and a higher pulmonary regurgitant fraction, thus acting as a marker of progressive impairment of myocardial function. Moreover, LGE in ToF patients correlated with the onset of arrhythmias, and with serum biomarkers indicative of myocardial stress and fibrosis.

CONCLUSIONS

LGE could be used in the follow-up repaired ToF patients as its appraisal can provide information concerning cardiac dysfunction. Moreover, it may be ideal to aim towards a common framework for standardizing assessment and quantification of LGE in ToF patients.

Technique and protocols for cardiothoracic time-resolved contrast-enhanced magnetic resonance angiography sequences: a systematic review

AIM

To review contrast medium administration protocols used for cardiothoracic applications of time-resolved, contrast-enhanced magnetic resonance angiography (MRA) sequences.

MATERIALS AND METHODS

A systematic search of the literature (Medline/EMBASE) was performed to identify articles utilising time-resolved MRA sequences, focusing on type of sequence, adopted technical parameters, contrast agent (CA) issues, and acquisition workflow. Study design, year of publication, population, magnetic field strength, type, dose, and injection parameters of CA, as well as technical parameters of time-resolved MRA sequences were extracted.

RESULTS

Of 117 retrieved articles, 16 matched the inclusion criteria. The study design was prospective in 9/16 (56%) articles, and study population ranged from 5 to 185 patients, for a total of 506 patients who underwent cardiothoracic time-resolved MRA. Magnetic field strength was 1.5 T in 13/16 (81%), and 3 T in 3/16 (19%) articles. The administered CA was gadobutrol (Gadovist) in 6/16 (37%) articles, gadopentetate dimeglumine (Magnevist) in 5/16 (31%), gadobenate dimeglumine (MultiHance) in 2/16 (13%), gadodiamide (Omniscan) in 2/16 (13%), gadofosveset trisodium (Ablavar, previously Vasovist) in 1/16 (6%). CA showed highly variable doses among studies: fixed amount or based on patient body weight (0.02-0.2 mmol/kg) and was injected with a flow rate ranging 1-5 ml/s. Sequences were TWIST in 13/16 (81%), TRICKS in 2/16 (13%), and CENTRA 1/16 articles (6%).

CONCLUSION

Time-resolved MRA sequences were adopted in different clinical settings with a large spectrum of technical approaches, mostly in association with different CA dose, type, and injection method. Further studies in relation to specific clinical indications are warranted to provide a common standardised acquisition protocol.

High versus Low Mechanical Index Imaging Diagnostic Ultrasound in Patients with Myocardial Infarction: A Therapeutic Application Study

Background

High mechanical index impulse of ultrasound is used for diagnosis of microvascular coronary obstruction and the necrotic area, but an experimental model study suggested that it can restore microvascular and epicardial coronary flow. The purposes of the study were to test the safety and therapeutic efficacy of high acoustic energy diagnostic ultrasound in patients with ST-segment elevation myocardial infarction.

Material/Methods

Patients with ST-segment elevation myocardial infarction subjected to a low (n=199) or high (n=251) mechanical index ultrasound before and after percutaneous coronary interventions and echocardiographic parameters were evaluated. Coronary angiographies were performed for the assessment of culprit vessels. Thrombolysis in myocardial infarction flow grade 1 or 2 were considered as culprit vessels.

Results

Patients diagnosed through low acoustic energy ultrasound reported 235 infarct vessels and patients diagnosed through high acoustic energy ultrasound reported 300 infarct vessels. With respect to low acoustic energy, high acoustic energy reduced the number of culprit vessels at post-percutaneous coronary interventions at 48 hours before hospital discharge (P=0.015) and post-percutaneous coronary interventions at 1-month from the baseline interventions (P=0.043). Also, the maximum% ST-segment resolution and an ejection fraction of the left ventricle was increased and microvascular coronary obstruction in infarct vessels was decreased for both evaluation points. High acoustic energy could not affect heart rate (P=0.133) and oxygen saturation (P=0.079).

Conclusions

High acoustic energy ultrasound is a safe method for diagnosis of ST-segment elevation myocardial infarction and may have therapeutic applications.

Sinus of Valsalva Aneurysms: Basic Concepts and Imaging Evaluation Using Multidetector Computed Tomography

Sinuses of Valsalva aneurysms are rare cardiac anomalies with a varied clinical spectrum. The presentation may range from silent asymptomatic cases detected incidentally to catastrophic rupture. They are associated with potentially fatal complications; however, the prognosis after treatment is excellent, which mandates prompt and accurate diagnosis. Imaging is of paramount importance in diagnosis, treatment planning, and postsurgical follow-up. Echocardiography remains the initial investigation of choice; however, cardiac magnetic resonance imaging and computed tomography are being increasingly utilized as complementary imaging techniques. The latest generation multidetector computed tomography with its improved spatial and temporal resolution provides high-quality reconstructed images with reduced radiation burden. Moreover, it allows the simultaneous assessment of coronary arteries, thereby helping in mapping the ideal treatment option. Surgical repair remains the treatment of choice with percutaneous closure in selected patients.

Congenital heart disease in adults (when kids grow up) pediatric geriatric anesthesia

PURPOSE OF REVIEW

The current review focuses on the new development of adult congenital heart disease (ACHD) patients in the areas of imaging, percutaneous interventions, ventricular assist devices and transplantation.

RECENT FINDINGS

Since the last ACHD publication in the journal, several advances have been made in the evaluation and treatment of these patients. As CHD patients' longevity increases pregnancy, comorbities and acquired heart disease become a concern. Recent data show that the incidence of complications in low-risk CHD is not higher that the regular population. In addition, breakthrough research in percutaneous valve implantation has been published showing good outcomes but needing intensive care recovery in a significant number of patients. In the ACHD heart failure population, assist device and transplant fields mounting evidence shows that these therapies should not be the last resort since low-risk ACHD patient may have similar outcomes to those with acquired heart disease. Finally risk stratification is important in ACHD to define better ways to recover from surgery and anesthesia.

SUMMARY

The field of anesthesia for ACHD is growing with new indications for diagnostic, interventional and surgical procedures. Tailoring cardiac and noncardiac care to the different risk profile in ACHD patients will be defined in the next few years.

VIDEO ABSTRACT

Motta summary clip: http://links.lww.com/COAN/A65.

Left ventricular ischemia after arterial switch procedure: Role of myocardial perfusion scintigraphy and cardiac CT

Transposition of the great arteries is a congenital heart defect defined by an abnormal connection between the aorta, pulmonary artery, and the ventricles, resulting in parallel systemic and pulmonary circulations. Long-term follow-up data of patients who underwent correction via an arterial switch operation have recently shown that as a result of re-implantation of the coronary arteries in the neo-aorta, coronary stenosis and occlusion are relatively common complications. In this report, we discuss two cases illustrating the added value of myocardial perfusion imaging (MPI) and cardiac CT for the assessment of these patients. Based on the available literature we conclude that MPI and cardiac CT are excellent non-invasive methods to evaluate coronary anatomy and myocardial function also in this specific group of patients.

Repaired Congenital Heart Disease in Older Children and Adults: Up-to-Date Practical Assessment and Characteristic Imaging Findings

Because of a recent increase in survival rates and life expectancy of patients with congenital heart disease (CHD), radiologists are facing new challenges when imaging the peculiar anatomy of individuals with repaired CHD. Cardiac computed tomography and magnetic resonance are paramount noninvasive imaging tools that are useful in assessing patients with repaired CHD, and both techniques are increasingly performed in centers where CHD is not the main specialization. This review provides general radiologists with insight into the main issues of imaging patients with repaired CHD, and the most common findings and complications of each individual pathology and its repair.

Cardiac magnetic resonance imaging as a prognostic biomarker in treatment-naïve pulmonary hypertension

PURPOSE

Targeted treatment for pulmonary arterial hypertension (PAH), diagnosed via right heart catheterization (RHC), has been shown to improve morbidity and mortality. Identifying characteristics that predict clinical worsening has been challenging. We sought to evaluate the role of cardiac Magnetic Resonance Imaging (CMR) as a predictor of clinical worsening in a cohort of treatment-naïve pulmonary hypertension (PH) patients.

METHODS

We performed a retrospective single center analysis of all adults with newly diagnosed treatment-naïve PH between January 1st 2013 and January 1st 2019. Patients with World Health Organization (WHO)-Group I PAH or WHO-Group II/III PH disease, who underwent both CMR (Signa Horizon 1.5 T, General Electric, Milwaukee, WI and Siemens Espree 1.5 T, Munich, Germany) and RHC testing prior to targeted PAH treatment, were included for analysis. Cox proportional hazards models were constructed.

RESULTS

A total of 38 patients, of which 12 (32 %) experienced the primary outcome of clinical worsening. were included in the final analysis, Patients with clinical worsening were significantly more likely to have RV dysfunction by CMR (including lower RV ejection fraction (HR 0.93, p = 0.007) and more RV dilation (HR 1.02, p = 0.005-0.021)) and RHC (including worse pulmonary vascular resistance (HR 1.32, p < 0.001)), even after adjustment for disease severity. Both CMR and RHC measures of RV dysfunction were found to be equally effective in predicting clinical worsening, regardless of PH etiology.

CONCLUSIONS

In treatment-naïve PH patients, including those with WHO-Group II/III disease, both CMR and RHC measures independently and significantly predicted clinical worsening, even after adjustment for disease severity.

Emerging clinical applications of strain imaging and three-dimensional echocardiography for the assessment of ventricular function in adult congenital heart disease

Management of congenital heart disease (CHD) in adults (ACHD) remains an ongoing challenge due to the presence of residual hemodynamic lesions and development of ventricular dysfunction in a large number of patients. Echocardiographic imaging plays a central role in clinical decision-making and selection of patients who will benefit most from catheter interventions or cardiac surgery.. Recent advances in both strain imaging and three-dimensional (3D)-echocardiography have significantly contributed to a greater understanding of the complex pathophysiological mechanisms involved in CHD. The aim of this paper is to provide an overview of emerging clinical applications of speckle-tracking imaging and 3D-echocardiography in ACHD with focus on functional assessment, ventriculo-ventricular interdependency, mechanisms of electromechanical delay, and twist abnormalities in adults with tetralogy of Fallot (TOF), a systemic RV after atrial switch repair or in double discordance ventricles, and in those with a Fontan circulation.

Cross-sectional imaging of congenital pulmonary artery anomalies

Congenital pulmonary artery (PA) anomalies comprise a rare and heterogeneous spectrum of disease, ranging from abnormal origins to complete atresia. They may present in early infancy or more insidiously in adulthood, often in association with congenital heart disease such as tetralogy of Fallot or other syndromes. In recent years, cross-sectional imaging, including computed tomography (CT) and magnetic resonance imaging (MRI), has become widely utilized for the noninvasive assessment of congenital PA diseases, supplementing echocardiography and at times supplanting invasive angiography. In this article, modern CT and MRI techniques for imaging congenital PA disorders are summarized. The key clinical features, cross-sectional imaging findings, and treatment options for the most commonly encountered entities are then reviewed. Emphasis is placed on the ever-growing role of cross-sectional imaging options in facilitating early and accurate diagnosis and tailored treatment.

Advanced Cardiac Imaging for Complex Adult Congenital Heart Diseases

The population of patients with adult congenital heart disease has grown and is currently estimated to include approximately 1 million people in the United States. Cardiologists and imagers frequently encounter complex patients who have undergone multiple prior operations and interventions. A myriad of imaging tests are currently available, including echocardiography, cardiovascular magnetic resonance imaging, and computed tomography, all of which collectively provide invaluable information on cardiac anatomy and hemodynamics. Advanced imaging plays a role in diagnosis and preprocedural planning and also determines the need and frequency of follow-up. This article provides a contemporary review of the current role of cardiac imaging in patients with complex congenital heart disease.

Interpretation and Reporting of Coronary Arteries in Transposition of the Great Arteries: Cross-sectional Imaging Perspective

Knowledge of coronary artery nomenclature in transposition of the great arteries is essential, given the increasing population of adults with congenital heart disease and greater utilization of imaging in these patients. This article reviews appropriate terminology for describing coronary artery anatomy, commonly encountered coronary artery patterns, and postoperative coronary complications in the setting of transposition of the great arteries.

Technological Advancements in Echocardiographic Assessment of Thoracic Aortic Dilatation: Head to Head Comparison Among Multidetector Computed Tomography, 2-Dimensional, and 3-Dimensional Echocardiography Measurements

PURPOSE

The aim of this study was to evaluate the feasibility and accuracy of 2-dimensional (2D) and 3-dimensional (3D) transthoracic echocardiography (2DTTE, 3DTTE) versus multidetector computed tomography (MDCT) in patients with ascending aortic (AA) dilation.

MATERIALS AND METHODS

Fifty consecutive patients with AA dilation were evaluated by 2DTTE, X-plane (XP) 3DTTE, and MDCT. Aorta diameters were measured at aortic annulus, aortic root (SIN), sinotubular junction, AA, aortic arch before the prebrachiocephalic artery (PRE), and before left subclavian artery (INTRA). Leading edge-to-leading edge (L-L) and inner-to-inner (I-I) measurements were compared with MDCT data.

RESULTS

Feasibility, quality of imaging, and accuracy was high with all echocardiographic methods. Specifically for MDCT maximum SIN diameter, the best correlation and agreement was obtained using XP maximum diameter at 3DTTE (MDCT: 44.8±7.4 mm vs. XP: 44.4±7.4 mm; r=0.975; bias=-0.4 mm). The same was true for AA maximum diameter at MDCT (MDCT: 46.6±8.1 mm vs. XP: 47.5±8.1 mm; r=0.991; bias=0.1 mm). For aortic arch the best correlation and agreement with MDCT were as follows: 2DTTE L-L diameter for arch PRE (MDCT: 37.9±5.3 mm vs. TTE: 36.6±4.5 mm; r=0.927; bias=-0.9 mm) and MDCT minimum diameter with XP minimum diameter for arch INTRA (MDCT: 28.2±5.0 mm vs. TTE 28.8±4.7 mm; r=0.939; bias=-0.3 mm).

CONCLUSION

In patients with aortic dilatation or aneurysm, new techniques (mainly 2D-3D probes allowing XP views) facilitate accuracy of aortic measurements at different sites of the vessel and allow standardization of analysis to better compare with MDCT.

Imaging in Congenital and Hereditary Abnormalities of the Interventricular Septum: Clinical Anatomy and Diagnostic Clues

Early identification of congenital heart diseases, specifically those affecting the structural integrity and function of the interventricular septum, in childhood is important toward decreasing the morbidity and mortality of those affected. We review the pertinent clinical and imaging manifestations for those with ventricular septal defects, ventricular septal aneurysms, tetralogy of Fallot, and hypertrophic (obstructive) cardiomyopathy, in addition to discussing first-line imaging studies, including echocardiography, and indications for advanced imaging.

Cross-sectional Areas of the Thoracic Aorta in Children and Adolescents With Repaired Tetralogy of Fallot Obtained by Cardiac Magnetic Resonance Angiography

PURPOSE

Dilatation of the thoracic aorta is a well-known finding in corrected Tetralogy of Fallot. Complications are rare but can be life-threatening. Standard 1-dimensional (1D) measurements have several limitations. We sought to establish contrast-enhanced magnetic resonance angiography cross-sectional areas of the aorta that could serve as reference values and to identify parameters that are associated with aortic dilatation.

MATERIALS AND METHODS

We enrolled 101 children and adolescents. The aortic areas were measured at the level of the aortic sinus (AS), the sinotubular junction (STJ), the ascending aorta (AA), the brachiocephalic trunk (TBC), and the descending aorta (DA). Sex-specific aortic dimensions were presented as percentile curves as well as regression equations. Furthermore volumetric and functional parameters as well as clinical data were analyzed to identify parameters that are associated with aortic dilatation.

RESULTS

Aortic areas (mm) for female subjects were 139+366×body surface area (BSA) for the AS, 134+255×BSA for the STJ, 113+239×BSA for the AA, 88+185×BSA proximal to the TBC, and 2.9+88×BSA for the DA. Aortic areas (mm) for male subjects were 162+403×BSA for the AS, 171+258×BSA for the STJ, 151+233×BSA for the AA, 73+206×BSA proximal to the TBC, and 21+80×BSA for the DA. The postoperative interval and age at examination were parameters associated with aortic size.

CONCLUSIONS

We provide aortic areas in children and adolescents after correction of Tetralogy of Fallot measured by contrast-enhanced magnetic resonance angiography. Our 2D data may better depict the geometry of enlarged aortae than standard 1D diameters and serve as reference values for evaluating aortic disease in these patients.