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Abe R, Fukuzawa K, Yoshihara C, Tano M, Saitoh S. Comparison of spin-echo echo planar imaging and gradient-recalled echo sequences in magnetic resonance elastography of liver at 1.5T same MRI scanner. Abdom Radiol (NY) 2024; 49:694-702. [PMID: 38012395 DOI: 10.1007/s00261-023-04098-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 11/29/2023]
Abstract
PURPOSE Magnetic resonance elastography (MRE) is used to measure liver stiffness with gradient-recalled echo (GRE)-based and spin-echo echo planar imaging (SE-EPI)-based sequences. We compared the liver stiffness (LS) values of the two sequences on a 1.5-T MR imaging scanner. METHODS This is a retrospective study. An MRE imaging section was obtained from a horizontal section of the liver. Region of interest was drawn on the elastogram, and the mean LS and pixel values were measured and compared. The correlations between proton density fat fraction, R2* values, and biochemical data from electronic medical records were confirmed, and multivariate analysis was performed. RESULTS The mean LS values were 3.01 ± 1.78 kPa for GRE and 3.13 ± 1.57 kPa for SE-EPI, showing excellent agreement and a strong correlation between the two sequences (correlation coefficient r = 0.96). The mean pixel values were 369.5 ± 142.7 pixels for GRE and 490.1 ± 197.9 pixels for SE-EPI, showing a significant difference by the Wilcoxon rank sum test (p < 0.01). There were no LS unmeasurable cases in SE-EPI, but seven (2.5%) were unmeasurable in GRE, and multivariate analysis showed a significant difference with p < 0.001 in R2* values (mean, 92.7 Hz) for the GRE method. CONCLUSION The GRE and SE-EPI methods were comparable for LS measurements in 1.5-T liver MRE, indicating that SE-EPI MRE is more useful because GRE MRE may not measure cases with high R2* values and the region of interest tends to be smaller.
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Affiliation(s)
- Ryouna Abe
- Department of Radiological Technology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, Japan.
| | - Kei Fukuzawa
- Department of Radiological Technology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, Japan
| | - Chiharu Yoshihara
- Department of Radiological Technology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, Japan
| | - Masakatsu Tano
- Department of Radiological Technology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, Japan
| | - Satoshi Saitoh
- Department of Hepatology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, Japan
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Serai SD, Franchi-Abella S, Syed AB, Tkach JA, Toso S, Ferraioli G. MR and Ultrasound Elastography for Fibrosis Assessment in Children: Practical Implementation and Supporting Evidence- AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2024. [PMID: 38170833 DOI: 10.2214/ajr.23.30506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Quantitative MRI and ultrasound biomarkers of liver fibrosis have become important tools in the diagnosis and clinical management of children with chronic liver disease (CLD). In particular, MR elastography (MRE) is now routinely performed in clinical practice to evaluate the liver for fibrosis. Ultrasound shear-wave elastography has also become widely performed for this purpose, especially in young children. These noninvasive methods are increasingly used to replace liver biopsy for the diagnosis, quantitative staging, and treatment monitoring of patients with CLD. Although ultrasound has advantages of portability and lower equipment cost, available evidence indicates that MRI may have greater reliability and accuracy in liver fibrosis evaluation. In this AJR Expert Panel Narrative Review, we describe how, why, and when to use MRI- and ultrasound-based elastography methods for liver fibrosis assessment in children. Practical approaches are discussed for adapting and optimizing these methods in children, with consideration of clinical indications, patient preparation, equipment requirements, acquisition technique, as well as pitfalls and confounding factors. Guidance is provided for interpretation and reporting, and representative case examples are presented.
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Affiliation(s)
- Suraj D Serai
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia PA
| | - Stéphanie Franchi-Abella
- Université Paris-Saclay, Faculté de Médecine, Le Kremlin-Bicêtre, France
- AP-HP, Centre de Référence des maladies rares du foie de l'enfant, Service de radiologie pédiatrique diagnostique et interventionnelle, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- BIOMAPS UMR 9011 CNRS, Inserm, CEA, Orsay, France
| | - Ali B Syed
- Department of Radiology, Stanford University School of Medicine, Stanford, CA
| | - Jean A Tkach
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Seema Toso
- Department of Pediatric Radiology, University Children's Hospital Geneva, 6 rue Willy Donzé, CH 1211, Genéve 14, Suisse
| | - Giovanna Ferraioli
- Dipartimento di Scienze Clinico-Chirurgiche, Diagnostiche e Pediatriche, Medical School University of Pavia, Pavia 27100, Italy
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Brown MJ, Kolbe AB, Hull NC, Hilscher M, Kamath PS, Yalon M, Gu CN, Amawi ADT, Venkatesh SK, Wells ML. Imaging of Fontan-Associated Liver Disease. J Comput Assist Tomogr 2024; 48:1-11. [PMID: 37574655 DOI: 10.1097/rct.0000000000001533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
ABSTRACT The Fontan procedure is the definitive treatment for patients with single-ventricle physiology. Surgical advances have led to a growing number of patients surviving into adulthood. Fontan-associated liver disease (FALD) encompasses a spectrum of pathologic liver changes that occur secondary to altered physiology including congestion, fibrosis, and the development of liver masses. Assessment of FALD is difficult and relies on using imaging alongside of clinical, laboratory, and pathology information. Ultrasound, computed tomography, and magnetic resonance imaging are capable of demonstrating physiologic and hepatic parenchymal abnormalities commonly seen in FALD. Several novel imaging techniques including magnetic resonance elastography are under study for use as biomarkers for FALD progression. Imaging has a central role in detection and characterization of liver masses as benign or malignant. Benign FNH-like masses are commonly encountered; however, these can display atypical features and be mistaken for hepatocellular carcinoma (HCC). Fontan patients are at elevated risk for HCC, which is a feared complication and has a poor prognosis in this population. While imaging screening for HCC is widely advocated, no consensus has been reached regarding an optimal surveillance regimen.
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Affiliation(s)
- Mark J Brown
- From the Mayo Graduate School of Medicine: Mayo School of Graduate Medical Education
| | - Amy B Kolbe
- Department of Radiology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Nathan C Hull
- Department of Radiology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Moira Hilscher
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Patrick S Kamath
- Department of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Mayo Clinic
| | | | - Chris N Gu
- Department of Radiology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Ali Dean T Amawi
- Department of Internal Medicine, NYC Health and Hospital/Lincoln Medical Center, New York City, NY
| | - Sudhakar K Venkatesh
- Department of Radiology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Michael L Wells
- Department of Radiology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
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Téllez L, Payancé A, Tjwa E, Del Cerro MJ, Idorn L, Ovroutski S, De Bruyne R, Verkade HJ, De Rita F, de Lange C, Angelini A, Paradis V, Rautou PE, García-Pagán JC. EASL-ERN position paper on liver involvement in patients with Fontan-type circulation. J Hepatol 2023; 79:1270-1301. [PMID: 37863545 DOI: 10.1016/j.jhep.2023.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/06/2023] [Indexed: 10/22/2023]
Abstract
Fontan-type surgery is the final step in the sequential palliative surgical treatment of infants born with a univentricular heart. The resulting long-term haemodynamic changes promote liver damage, leading to Fontan-associated liver disease (FALD), in virtually all patients with Fontan circulation. Owing to the lack of a uniform definition of FALD and the competitive risk of other complications developed by Fontan patients, the impact of FALD on the prognosis of these patients is currently debatable. However, based on the increasing number of adult Fontan patients and recent research interest, the European Association for The Study of the Liver and the European Reference Network on Rare Liver Diseases thought a position paper timely. The aims of the current paper are: (1) to provide a clear definition and description of FALD, including clinical, analytical, radiological, haemodynamic, and histological features; (2) to facilitate guidance for staging the liver disease; and (3) to provide evidence- and experience-based recommendations for the management of different clinical scenarios.
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Affiliation(s)
- Luis Téllez
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), University of Alcalá, Madrid, Spain
| | - Audrey Payancé
- DHU Unity, Pôle des Maladies de l'Appareil Digestif, Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy, France; Université Denis Diderot-Paris 7, Sorbonne Paris Cité, Paris, France
| | - Eric Tjwa
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - María Jesús Del Cerro
- Pediatric Cardiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), University of Alcalá, Madrid, Spain
| | - Lars Idorn
- Department of Pediatrics, Section of Pediatric Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Ruth De Bruyne
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Ghent University Hospital, Belgium
| | - Henkjan J Verkade
- Department of Pediatrics, Beatrix Children's Hospital/University Medical Center Groningen, The Netherlands
| | - Fabrizio De Rita
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Charlotte de Lange
- Department of Pediatric Radiology, Queen Silvia Childrens' Hospital, Sahlgrenska University Hospital, Behandlingsvagen 7, 41650 Göteborg, Sweden
| | - Annalisa Angelini
- Pathology of Cardiac Transplantation and Regenerative Medicine Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Valérie Paradis
- Centre de recherche sur l'inflammation, INSERM1149, Université Paris Cité, Paris, France; Pathology Department, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Pierre Emmanuel Rautou
- AP-HP, Service d'Hépatologie, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, Clichy, France; Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Departament de Medicina i Ciències de la Salut, University of Barcelona, Barcelona, Spain; CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Spain.
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Greidanus PG, Pagano JJ, Escudero CA, Thompson R, Tham EB. Regional Elevation of Liver T1 in Fontan Patients. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:134-142. [PMID: 37969352 PMCID: PMC10642140 DOI: 10.1016/j.cjcpc.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/08/2023] [Indexed: 11/17/2023]
Abstract
Background Fontan-associated liver disease (FALD) is characterized by hepatic congestion and progressive hepatic fibrosis in patients with the Fontan operation. This condition is generally clinically silent until late, necessitating techniques for early detection. Liver T1 mapping has been used to screen for FALD, but without consideration of regional variations in T1 values. Methods Liver T1 measured with a liver-specific T1 mapping sequence (PROFIT1) in Fontan patients was compared with cohorts of patients with biventricular congenital heart disease (BiV-CHD) and controls with normal cardiac function and anatomy. Results Liver T1 was significantly elevated in the Fontan cohort (n = 20) compared with patients with BiV-CHD (n = 12) and controls (n = 9) (781, 678, and 675 milliseconds, respectively; P < 0.001), with a consistent pattern of significantly elevated T1 values in the peripheral compared with central liver regions (ΔT1 = 54, 2, and 11 milliseconds; P < 0.001). PROFIT1 also yielded simultaneous T2∗ maps and fat fraction values that were similar in all groups. Fontan liver T1 values were also significantly elevated as compared with BiV-CHD and controls as measured with the cardiac (modified Look-Locker inversion) acquisitions (728, 583, and 583 milliseconds, respectively; P < 0.001) and values correlated with PROFIT1 liver T1 (R = 0.87, P < 0.001). Conclusions Fontan patients have globally increased liver T1 values and consistent spatial variations, with higher values in the peripheral liver regions as compared with spatially uniform values in BiV-CHD and controls. The spatial patterns may provide insight into the progression of FALD. Liver T1 mapping studies should include uniform spatial coverage to avoid bias based on slice locations in this population.
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Affiliation(s)
- Paul G. Greidanus
- Division of Pediatric Cardiology, Stollery Children’s Hospital & Mazankowski Alberta Heart Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Joseph J. Pagano
- Division of Pediatric Cardiology, Stollery Children’s Hospital & Mazankowski Alberta Heart Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Carolina A. Escudero
- Division of Pediatric Cardiology, Stollery Children’s Hospital & Mazankowski Alberta Heart Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Richard Thompson
- Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Edythe B. Tham
- Division of Pediatric Cardiology, Stollery Children’s Hospital & Mazankowski Alberta Heart Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Evlice M, Bedir Ö, Coşkun M, Paçacı E, Cerşit S, Öcal L, Gürsoy MO, Şen Ö, Kurt İH. The relationship between echocardiographic parameters and albumin bilirubin (ALBI) score in patients with isolated secundum type atrial septal defect. Echocardiography 2023; 40:350-358. [PMID: 36973228 DOI: 10.1111/echo.15556] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/08/2023] [Accepted: 02/24/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND It has been shown that the increase in volume and pressure in the right heart chambers increases liver stiffness. The Albumin-Bilirubin (ALBI) score is a useful and easy-to-use score for objectively assessing liver function. There is no information in the literature about changes in ALBI score in patients with atrial septal defect (ASD). The aim of our study is to investigate the changes in ALBI score and its clinical impact in patients with ASD. METHODS Of the 206 analyzed patients, 77 were excluded. The remaining 129 patients with secundum type ASD with left to right shunt were divided into three groups; Group I (16 patients with Qp/Qs < 1.5 and defect diameter < 10 mm), Group II (52 patients with Qp/Qs > 1.5 and defect diameter 10-20 mm) and Group III (61 patients with Qp/Qs > 1.5 and defect diameter > 20 mm). The ALBI score was calculated based on serum albumin and total bilirubin levels using the following formula: ALBI = (log10 bilirubin [umol/L] * .66) + (albumin [g/L] * -.085). RESULTS ALBI scores as well as total bilirubin levels, transaminases, and functional-structural heart abnormalities (increase in RA and RV dimensions, sPAP, ASD size and decrease in LVEF and TAPSE) showed a significant increasing trend from Group I to Group III (p < .001 for all comparisons). The mean ALBI scores for Group I, Group II, and Group III were -3.71 ± .37, -3.51 ± .25, and -3.27 ± .34, respectively. In multivariate linear regression analysis, ASD size, sPAP, RV-RA diameter were found to be significantly associated with increased ALBI score. CONCLUSION The ALBI score offers a simple, evidence-based, objective, and discriminatory method of assessing liver function in patients with ASD. ASD size, sPAP, RV and RA diameters were significantly associated with ALBI score.
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Affiliation(s)
- Mert Evlice
- Department of Cardiology, Health Sciences University -Adana City Training and Research Hospital, Adana, Turkey
| | - Ömer Bedir
- Department of Cardiology, Health Sciences University -Adana City Training and Research Hospital, Adana, Turkey
| | - Mükremin Coşkun
- Department of Cardiology, Health Sciences University -Adana City Training and Research Hospital, Adana, Turkey
| | - Emre Paçacı
- Department of Cardiology, Health Sciences University -Adana City Training and Research Hospital, Adana, Turkey
| | - Sinan Cerşit
- Department of Cardiology, Health Sciences University -Kartal Koşuyolu Training and Research Hospital, İstanbul, Turkey
| | - Lütfi Öcal
- Department of Cardiology, Health Sciences University -Kartal Koşuyolu Training and Research Hospital, İstanbul, Turkey
| | | | - Ömer Şen
- Department of Cardiology, Health Sciences University -Adana City Training and Research Hospital, Adana, Turkey
| | - İbrahim Halil Kurt
- Department of Cardiology, Health Sciences University -Adana City Training and Research Hospital, Adana, Turkey
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7
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T1 mapping of the myocardium and liver in the single ventricle population. Pediatr Radiol 2022; 53:1092-1099. [PMID: 36539566 DOI: 10.1007/s00247-022-05560-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/14/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Fontan associated liver disease (FALD) is an increasingly recognized complication of the single ventricle circulation characterized by hepatic venous congestion leading to hepatic fibrosis. Within the Fontan myocardium, fibrotic myocardial remodeling may occur and lead to ventricular dysfunction. Magnetic resonance imaging (MRI) T1 mapping can characterize both myocardial and liver properties. OBJECTIVE The aim of this study was to compare myocardial and liver T1 between single ventricle patients with and without a Fontan and biventricular controls. MATERIALS AND METHODS A retrospective study of 3 groups of patients: 16 single ventricle patients before Fontan (SVpre 2 newborns, 9 pre-Glenn, 5 pre-Fontan, 31% single right ventricle [SRV]), 16 Fontans (56% SRV) and 10 repaired d-transposition of the great arteries (TGA). Native modified Look-Locker inversion T1 times were measured in the myocardium and liver. Cardiac MRI parameters, myocardial and liver T1 values were compared in the three groups. Correlations were assessed between liver T1 and cardiac parameters. RESULTS Myocardial T1 was higher in SVpre (1,056 ± 48 ms) and Fontans (1,047 ± 41 ms) compared to TGA (1,012 ± 48 ms, P < 0.05). Increased liver T1 was found in both SVpre (683 ± 82 ms) and Fontan (727 ± 49 ms) patients compared to TGA patients (587 ± 58 ms, P < 0.001). There was no difference between single left ventricle (SLV) versus SRV myocardial or liver T1. Liver T1 showed moderate correlations with myocardial T1 (r = 0.48, confidence interval [CI] 0.26-0.72) and ejection fraction (r = -0.36, CI -0.66-0.95) but not with other volumetric parameters. CONCLUSION Increased liver T1 at both pre- and post-Fontan stages suggests there are intrinsic liver abnormalities early in the course of single ventricle palliation. Increased myocardial T1 and its relationship to liver T1 suggest a combination of edema from passive venous congestion and/or myocardial fibrosis occurring in this population. Liver T1 may provide an earlier marker of liver disease warranting further study.
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Serai SD, Elsingergy MM, Hartung EA, Otero HJ. Liver and spleen volume and stiffness in patients post-Fontan procedure and patients with ARPKD compared to normal controls. Clin Imaging 2022; 89:147-154. [PMID: 35835018 DOI: 10.1016/j.clinimag.2022.06.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/27/2022] [Accepted: 06/28/2022] [Indexed: 01/29/2023]
Abstract
PURPOSE Both congestive (patients post-Fontan hepatopathy) and congenital (patients with ARPKD) disease can lead to hepatic fibrosis and portal hypertension with eventual development of splenomegaly. We investigated liver and spleen stiffness as measured by MRE between post-Fontan, ARPKD patients and controls independent of organ volume. METHODS Our study included 122 subjects (70 Fontan patients, 14 ARPKD patients, and 38 controls). The mean MRE liver and spleen stiffness values of Fontan patients and patients with ARPKD were compared to controls. Similarly, the liver and spleen volumes of the Fontan patients and patients with ARPKD were then compared to the volumes of controls. RESULTS Post-Fontan and ARPKD patients, mean liver stiffness, mean liver volume as well as mean spleen stiffness and mean spleen volume were higher than mean liver stiffness, mean liver volume, mean spleen stiffness, and mean spleen volume of controls. While liver stiffness correlated to liver volume in controls, we found no correlation between stiffness and volume in either Fontan or ARPKD patients, which indicates MRE's ability to act as an independent biomarker. However, these findings are not true in the spleen, where there is significant association between volume and stiffness in patients with ARPKD, but not in Fontan patients or controls. CONCLUSION Liver and spleen stiffness and volumes are significantly different among Fontan patients, ARPKD patients, and controls. Our findings suggest that beyond diagnosing fibrosis, MRE cut-off values could be disease-specific since not only the severity but the underlying pathology causing organ congestion or fibrosis influences MRE results.
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Affiliation(s)
- Suraj D Serai
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Mohamed M Elsingergy
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Erum A Hartung
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Hansel J Otero
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Serai S, Tsitsiou Y, Wilkins B, Ghosh A, Cahill A, Biko D, Rychik J, Rand E, Goldberg D. MR elastography-based staging of liver fibrosis in Fontan procedure associated liver disease is confounded by effects of venous congestion. Clin Radiol 2022; 77:e776-e782. [DOI: 10.1016/j.crad.2022.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/31/2022] [Accepted: 06/24/2022] [Indexed: 11/03/2022]
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10
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Dhillon JK, Fong MW, Fong TL. Use of liver stiffness measurements in acute decompensated heart failure: new applications of a non-invasive technique. ESC Heart Fail 2022; 9:2800-2807. [PMID: 35821206 DOI: 10.1002/ehf2.14038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 05/18/2022] [Accepted: 06/08/2022] [Indexed: 11/10/2022] Open
Abstract
Heart failure (HF) is a complex disease associated with multisystem organ failure, recurrent hospital admissions, and increased mortality. Acute decompensated heart failure (ADHF) increases central venous pressure (CVP) with resultant hepatic congestion, and this relationship has prognostic significance. The gold standard method of measuring CVP, right heart catheterization, is invasive and costly, prompting further investigation into more accurate non-invasive assessments in HF patients, including liver elastography. Liver elastography relies on imaging techniques to assess liver stiffness measurements (LSM), with high values equating to increased stiffness. While this was developed to assess fibrosis in liver disease, LSM also reflect increased CVP and hepatic congestion. Multiple studies involving ADHF patients, find that increased LSM are independently predictive of increased cardiac events, all-cause mortality, and worse post-operative outcome after both acute HF exacerbation and left ventricular assist device (LVAD) placement. In this review, we discuss the role of LSM as a surrogate for CVP and their applications in determining prognosis in both the ADHF and LVAD populations.
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Affiliation(s)
- Jaspreet K Dhillon
- Department of Internal Medicine, Los Angeles County University of Southern California Medical Center, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Michael W Fong
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Tse-Ling Fong
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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Hilscher MB, Wells ML, Venkatesh SK, Cetta F, Kamath PS. Fontan-associated liver disease. Hepatology 2022; 75:1300-1321. [PMID: 35179797 DOI: 10.1002/hep.32406] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/21/2021] [Accepted: 12/27/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Moira B Hilscher
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Michael L Wells
- Division of Abdominal ImagingDepartment of RadiologyMayo ClinicRochesterMinnesotaUSA
| | - Sudhakar K Venkatesh
- Division of Abdominal ImagingDepartment of RadiologyMayo ClinicRochesterMinnesotaUSA
| | - Frank Cetta
- Division of Pediatric CardiologyDepartment of Pediatric and Adolescent MedicineMayo ClinicRochesterMinnesotaUSA
| | - Patrick S Kamath
- Division of Gastroenterology and HepatologyDepartment of MedicineMayo ClinicRochesterMinnesotaUSA
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12
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Sethasathien S, Leemasawat K, Silvilairat S, Sittiwangkul R, Chattipakorn SC, Chattipakorn N. Screening modalities for the diagnosis of Fontan-associated liver disease: evidence from the past for future development. Am J Transl Res 2022; 14:1433-1453. [PMID: 35422957 PMCID: PMC8991157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 02/06/2022] [Indexed: 06/14/2023]
Abstract
Approximately 70,000 patients who have undergone the Fontan operation worldwide survive into adulthood, however the majority of these patients are faced with long-term post-operative complications due to specific hemodynamic changes. Fontan-associated liver disease (FALD) is a challenging complication characterized by various spectra. Of these, liver congestion and liver fibrosis potentially lead to cirrhosis and liver nodules. The most serious condition associated with the development of liver nodules is hepatocellular carcinoma. Various non-invasive modalities including blood tests, ultrasound scans of the upper abdomen, ultrasound elastography of the liver, computed tomography scans, magnetic resonance imaging and magnetic resonance elastography of the liver have been used as alternatives to liver biopsies for FALD assessment in post-Fontan patients. To date, a detailed understanding of the pathophysiology and natural history of these patients, and the most appropriate modality for the effective investigation of this condition is incomplete. In this comprehensive review, reports regarding the currently available screening modalities used in the detection of FALD are summarized and discussed. The findings of this review, including identification of any current knowledge gaps, can pave the way for the development of effective future strategies in the surveillance and ultimately the treatment of post-Fontan patients.
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Affiliation(s)
- Saviga Sethasathien
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Chiang Mai UniversityChiang Mai 50200, Thailand
| | - Krit Leemasawat
- Division of Cardiovascular Diseases, Department of Medicine, Faculty of Medicine, Chiang Mai UniversityChiang Mai 50200, Thailand
| | - Suchaya Silvilairat
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Chiang Mai UniversityChiang Mai 50200, Thailand
| | - Rekwan Sittiwangkul
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Chiang Mai UniversityChiang Mai 50200, Thailand
| | - Siriporn C Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai UniversityChiang Mai 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai UniversityChiang Mai 50200, Thailand
| | - Nipon Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai UniversityChiang Mai 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai UniversityChiang Mai 50200, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of Medicine, Chiang Mai UniversityChiang Mai 50200, Thailand
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13
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Chen J, Martin-Mateos R, Li J, Yin Z, Chen J, Lu X, Glaser KJ, Mounajjed T, Yashiro H, Siegelman J, Winkelmann CT, Wang J, Ehman RL, Shah VH, Yin M. Multiparametric magnetic resonance imaging/magnetic resonance elastography assesses progression and regression of steatosis, inflammation, and fibrosis in alcohol-associated liver disease. Alcohol Clin Exp Res 2021; 45:2103-2117. [PMID: 34486129 PMCID: PMC8602761 DOI: 10.1111/acer.14699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/25/2021] [Accepted: 08/13/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) and MRI-based elastography (MRE) are the most promising noninvasive techniques in assessing liver diseases. The purpose of this study was to evaluate an advanced multiparametric imaging method for staging disease and assessing treatment response in realistic preclinical alcohol-associated liver disease (ALD). METHODS We utilized four different preclinical mouse models in our study: Model 1-mice were fed a fast-food diet and fructose water for 48 weeks to induce nonalcoholic fatty liver disease; Model 2-mice were fed chronic-binge ethanol (EtOH) for 10 days or 8 weeks to induce liver steatosis/inflammation. Two groups of mice were treated with interleukin-22 at different time points to induce disease regression; Model 3-mice were administered CCl4 for 2 to 4 weeks to establish liver fibrosis followed by 2 or 4 weeks of recovery; and Model 4-mice were administered EtOH plus CCl4 for 12 weeks. Mouse liver imaging biomarkers including proton density fat fraction (PDFF), liver stiffness (LS), loss modulus (LM), and damping ratio (DR) were assessed. Liver and serum samples were obtained for histologic and biochemical analyses. Ordinal logistic regression and generalized linear regression analyses were used to model the severity of steatosis, inflammation, and fibrosis, and to assess the regression of these conditions. RESULTS Multiparametric models with combinations of biomarkers (LS, LM, DR, and PDFF) used noninvasively to predict the histologic severity and regression of steatosis, inflammation, and fibrosis were highly accurate (area under the curve > 0.84 for all). A three-parameter model that incorporates LS, DR, and ALT predicted histologic fibrosis progression (r = 0.84, p < 0.0001) and regression (r = 0.79, p < 0.0001) as measured by collagen content in livers. CONCLUSION This preclinical study provides evidence that multiparametric MRI/MRE can be used noninvasively to assess disease severity and monitor treatment response in ALD.
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Affiliation(s)
- Jingbiao Chen
- The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Rosa Martin-Mateos
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
- Gastroenterology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Jiahui Li
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ziying Yin
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jie Chen
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Radiology, West China Hospital, Chengdu, China
| | - Xin Lu
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Hiroaki Yashiro
- Research and Development, Takeda Pharmaceuticals International Co., Cambridge, MA, USA
| | - Jenifer Siegelman
- Research and Development, Takeda Pharmaceuticals International Co., Cambridge, MA, USA
| | | | - Jin Wang
- The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | | | - Vijay H. Shah
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Meng Yin
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
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14
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Rodriguez De Santiago E, Téllez L, Guerrero A, Albillos A. Hepatocellular carcinoma after Fontan surgery: A systematic review. Hepatol Res 2021; 51:116-134. [PMID: 33037858 DOI: 10.1111/hepr.13582] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/29/2020] [Accepted: 10/01/2020] [Indexed: 02/08/2023]
Abstract
AIM Fontan surgery is often the procedure of choice for patients with congenital single effective ventricle. In the long term, elevated systemic venous pressure and chronic ischemia following this procedure could lead to advanced chronic liver disease and there is also a risk of hepatocellular carcinoma (HCC). This review systematically summarizes the characteristics and outcomes of this rare condition. METHODS PubMed and Embase databases were searched from inception to January 2020 for studies reporting on HCC after Fontan surgery. The factors analyzed were clinical presentation, histology, imaging findings, treatments, and survival. Our primary analysis was based on biopsy-proven HCC. RESULTS The records selected were 26 observational studies (19 case reports/case series and seven cohort studies) including 65 biopsy-proven HCC. Age at the time of HCC diagnosis ranged from 12 to 52 years, and 62% of the patients were female. Only one case occurred earlier than 10 years after Fontan surgery. Twenty patients had no imaging or histological evidence of liver cirrhosis and 78.3% had elevated α-fetoprotein levels. Advanced stage was the most common at diagnosis. The most frequent treatments were transarterial chemoembolization (n = 18) and surgery (n = 12). One-year survival was 50% and only four patients (6.2%) were under liver imaging surveillance. We also analyzed 17 patients with non-biopsy-proven HCC. CONCLUSIONS After Fontan surgery, HCC usually occurs at least 10 years later and can develop in the absence of cirrhosis. Biopsy is mandatory to confirm the diagnosis. Patients were diagnosed at a late stage and survival outcomes were poor, highlighting a need for liver surveillance.
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Affiliation(s)
- Enrique Rodriguez De Santiago
- Department of Gastroenterology and Hepatology, Ramón y Cajal University Hospital, University of Alcala, Ramón y Cajal Health Research Institute (IRYCIS), Madrid, Spain
| | - Luis Téllez
- Department of Gastroenterology and Hepatology, Ramón y Cajal University Hospital, University of Alcala, Ramón y Cajal Health Research Institute (IRYCIS), Madrid, Spain
| | - Antonio Guerrero
- Department of Gastroenterology and Hepatology, Ramón y Cajal University Hospital, University of Alcala, Ramón y Cajal Health Research Institute (IRYCIS), Madrid, Spain
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Ramón y Cajal University Hospital, University of Alcala, Ramón y Cajal Health Research Institute (IRYCIS), Madrid, Spain
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15
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de Lange C, Thrane KJ, Thomassen KS, Geier O, Nguyen B, Tomterstad A, Ording Müller LS, Thaulow E, Almaas R, Døhlen G, Suther KR, Möller T. Hepatic magnetic resonance T1-mapping and extracellular volume fraction compared to shear-wave elastography in pediatric Fontan-associated liver disease. Pediatr Radiol 2021; 51:66-76. [PMID: 33033916 PMCID: PMC7796890 DOI: 10.1007/s00247-020-04805-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 06/10/2020] [Accepted: 08/10/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Children with Fontan circulation are at risk of developing hepatic fibrosis/cirrhosis. Reliable noninvasive monitoring techniques are lacking or under development. OBJECTIVE To investigate surrogate indicators of hepatic fibrosis in adolescents with Fontan circulation by evaluating hepatic magnetic resonance (MR) T1 mapping and extracellular volume fraction measurements compared to US shear-wave elastography. MATERIALS AND METHODS We analyzed hepatic native T1 times and extracellular volume fractions with modified Look-Locker inversion recovery. Liver stiffness was analyzed with shear-wave elastography. We compared results between 45 pediatric patients ages 16.7±0.6 years with Fontan circulation and 15 healthy controls ages 19.2±1.2 years. Measurements were correlated to clinical and hemodynamic data from cardiac catheterization. RESULTS MR mapping was successful in 35/45 patients, revealing higher hepatic T1 times (774±44 ms) than in controls (632±52 ms; P<0.001) and higher extracellular volume fractions (47.4±5.0%) than in controls (34.6±3.8%; P<0.001). Liver stiffness was 1.91±0.13 m/s in patients vs. 1.20±0.10 m/s in controls (P<0.001). Native T1 times correlated with central venous pressures (r=0.5, P=0.007). Native T1 was not correlated with elastography in patients (r=0.2, P=0.1) or controls (r = -0.3, P=0.3). Extracellular volume fraction was correlated with elastography in patients (r=0.5, P=0.005) but not in controls (r=0.2, P=0.6). CONCLUSION Increased hepatic MR relaxometry and shear-wave elastography values in adolescents with Fontan circulation suggested the presence of hepatic fibrosis or congestion. Central venous pressure was related to T1 times. Changes were detected differently with MR relaxometry and elastography; thus, these techniques should not be used interchangeably in monitoring hepatic fibrosis.
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Affiliation(s)
- Charlotte de Lange
- Division of Radiology and Nuclear Medicine, Section of Paediatric Radiology, Oslo University Hospital, Oslo, Norway. .,Department of Radiology and Clinical Physiology, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Rondv 10, S-41615, Göteborg, Sweden.
| | - Karl Julius Thrane
- Division of Radiology and Nuclear Medicine, Section of Paediatric Radiology, Oslo University Hospital, Oslo, Norway
| | - Kristian S. Thomassen
- Division of Radiology and Nuclear Medicine, Section of Paediatric Radiology, Oslo University Hospital, Oslo, Norway
| | - Oliver Geier
- Department of Physics, Oslo University Hospital, Oslo, Norway
| | - Bac Nguyen
- Division of Radiology and Nuclear Medicine, Section of Paediatric Radiology, Oslo University Hospital, Oslo, Norway
| | - Anders Tomterstad
- Division of Radiology and Nuclear Medicine, Section of Paediatric Radiology, Oslo University Hospital, Oslo, Norway
| | - Lil-Sofie Ording Müller
- Division of Radiology and Nuclear Medicine, Section of Paediatric Radiology, Oslo University Hospital, Oslo, Norway
| | - Erik Thaulow
- Department of Paediatric Cardiology, Oslo University Hospital, Oslo, Norway ,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Runar Almaas
- Department of Paediatric Research and Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Gaute Døhlen
- Department of Paediatric Cardiology, Oslo University Hospital, Oslo, Norway
| | - Kathrine Rydén Suther
- Division of Radiology and Nuclear Medicine, Section of Paediatric Radiology, Oslo University Hospital, Oslo, Norway
| | - Thomas Möller
- Department of Paediatric Cardiology, Oslo University Hospital, Oslo, Norway
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16
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Borquez AA, Silva-Sepulveda J, Lee JW, Vavinskaya V, Vodkin I, El-Sabrout H, Towbin R, Perry JC, Moore JW, El-Said HG. Transjugular liver biopsy for Fontan associated liver disease surveillance: Technique, outcomes and hemodynamic correlation. Int J Cardiol 2020; 328:83-88. [PMID: 33278420 DOI: 10.1016/j.ijcard.2020.11.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 09/17/2020] [Accepted: 11/18/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Fontan associated liver disease (FALD) is attributed to the limitations of the Fontan circulation, resulting in congestive hepatopathy. The technique and outcomes of transjugular liver biopsies (TJLB) in Fontan patients warrant definition as part of a rigorous FALD surveillance program. METHOD Four year review of patients with Fontan physiology who underwent a TJLB during surveillance catheterizations. Biopsy site, technique, histology, angiography, hemodynamics, and complications were reviewed to assess correlation of biopsy scores with simultaneously obtained catheterization hemodynamics. RESULTS 125 patients with a TJLB from 10/1/14 to 5/1/18. Median age 17 years (2-50.5). Technical success 100% (125/125), all samples diagnostic. 17% (21) accessed via the left internal jugular vein, secondary to right IJ occlusion or Heterotaxy syndrome. No patients had superior compartment obstruction preventing transjugular approach. 3.2% complication rate (4/125). Complications were early in the experience, including capsular perforation (2), renal hematoma (1) and hemobilia (1), all without long-term effect and all avoidable. After standardized entry/exit angiography was adopted, no further complications noted. There is a significant correlation between the newly described modified Ishak congestive hepatic fibrosis (ICHF) score with mean Fontan pressure, time from Fontan and cardiac index. CONCLUSIONS TJLB is an alternate method for obtaining critical FALD surveillance data, with lower complication rates that traditional techniques. Vascular anomalies in Fontan physiology appear common and warrant pre-biopsy assessment. There is a significant correlation between biopsy score, time from Fontan, mean Fontan pressure and cardiac index.
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Affiliation(s)
- Alejandro A Borquez
- San Diego School of Medicine, Department of Pediatrics, Division of Pediatric Cardiology, University of California, USA.
| | - Jose Silva-Sepulveda
- San Diego School of Medicine, Department of Pediatrics, Division of Pediatric Cardiology, University of California, USA
| | - Jesse W Lee
- San Diego School of Medicine, Department of Pediatrics, Division of Pediatric Cardiology, University of California, USA
| | - Vera Vavinskaya
- San Diego School of Medicine, Department of Pathology, University of California, USA
| | - Irine Vodkin
- San Diego School of Medicine, Department of Gastroenterology, University of California, USA
| | - Hannah El-Sabrout
- San Diego School of Medicine, Department of Pediatrics, Division of Pediatric Cardiology, University of California, USA
| | - Richard Towbin
- Department of Radiology, Phoenix Children's Hospital, USA
| | - James C Perry
- San Diego School of Medicine, Department of Pediatrics, Division of Pediatric Cardiology, University of California, USA
| | - John W Moore
- San Diego School of Medicine, Department of Pediatrics, Division of Pediatric Cardiology, University of California, USA
| | - Howaida G El-Said
- San Diego School of Medicine, Department of Pediatrics, Division of Pediatric Cardiology, University of California, USA
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17
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MR elastography of liver: current status and future perspectives. Abdom Radiol (NY) 2020; 45:3444-3462. [PMID: 32705312 DOI: 10.1007/s00261-020-02656-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 07/06/2020] [Accepted: 07/09/2020] [Indexed: 02/08/2023]
Abstract
Non-invasive evaluation of liver fibrosis has evolved over the last couple of decades. Currently, elastography techniques are the most widely used non-invasive methods for clinical evaluation of chronic liver disease (CLD). MR elastography (MRE) of the liver has been used in the clinical practice for nearly a decade and continues to be widely accepted for detection and staging of liver fibrosis. With MRE, one can directly visualize propagating shear waves through the liver and an inversion algorithm in the scanner automatically converts the shear wave properties into an elastogram (stiffness map) on which liver stiffness can be calculated. The commonly used MRE method, two-dimensional gradient recalled echo (2D-GRE) sequence has produced excellent results in the evaluation of liver fibrosis in CLD from various etiologies and newer clinical indications continue to emerge. Advances in MRE technique, including 3D MRE, automated liver elasticity calculation, improvements in shear wave delivery and patient experience, are promising to provide a faster and more reliable MRE of liver. Innovations, including evaluation of mechanical parameters, such as loss modulus, displacement, and volumetric strain, are promising for comprehensive evaluation of CLD as well as understanding pathophysiology, and in differentiating various etiologies of CLD. In this review, the current status of the MRE of liver in CLD are outlined and followed by a brief description of advanced techniques and innovations in MRE of liver.
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Magnetic resonance elastography could serve as a non-invasive quantitative screening study in the post-Fontan patient population. Abdom Radiol (NY) 2020; 45:3378-3379. [PMID: 32020260 DOI: 10.1007/s00261-020-02423-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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19
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Mojtahed A, Gee MS, Yokoo T. Pearls and Pitfalls of Metabolic Liver Magnetic Resonance Imaging in the Pediatric Population. Semin Ultrasound CT MR 2020; 41:451-461. [DOI: 10.1053/j.sult.2020.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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20
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Fontan-associated liver disease: pathophysiology, investigations, predictors of severity and management. Eur J Gastroenterol Hepatol 2020; 32:907-915. [PMID: 31851099 DOI: 10.1097/meg.0000000000001641] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cardiac hepatopathy is the liver injury resulting from congestion and ischaemia associated with acute or chronic heart failure. The improved longevity of adults with operated congenital heart disease who develop heart failure as an increasingly late event makes this form of liver injury increasingly clinically relevant. Patients with congenital heart disease with a single ventricle anomaly, who require creation of a Fontan circulation, are particularly vulnerable as they have elevated venous filling pressures with chronic liver congestion. Progression to liver fibrosis and eventually cirrhosis may occur, with its associated risks of liver failure and hepatocellular carcinoma. This risk likely increases over the patient's lifetime, related to the duration post-surgical repair and reflects the chronicity of congestion. Liver biopsy is rarely performed due to a higher risk of complications in the setting of elevated venous pressures, and the frequent use of anticoagulation. Non-invasive methods of liver assessment are poorly validated and different factors require consideration compared to other chronic liver diseases. This review discusses the current understanding of cardiac hepatopathy in congenital heart disease patients with a Fontan circulation. This entity has recently been called Fontan Associated Liver Disease in the literature, with the term useful in recognising that the pathophysiology is incompletely understood, and that long-standing venous pressure elevation and hypoxaemia are presumed to play an additional significant role in the pathogenesis of the liver injury.
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Newly Developed Methods for Reducing Motion Artifacts in Pediatric Abdominal MRI: Tips and Pearls. AJR Am J Roentgenol 2020; 214:1042-1053. [PMID: 32023117 DOI: 10.2214/ajr.19.21987] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE. The purpose of this article is to review established and emerging methods for reducing motion artifacts in pediatric abdominal MRI. CONCLUSION. Clearly understanding the strengths and limitations of motion reduction methods can enable practitioners of pediatric abdominal MRI to select and combine the appropriate techniques and potentially reduce the need for sedation and anesthesia.
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22
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Hilscher MB, Kamath PS. Congenital Heart Disease and the Liver. Clin Liver Dis (Hoboken) 2019; 14:138-141. [PMID: 31709041 PMCID: PMC6832097 DOI: 10.1002/cld.828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 03/15/2019] [Indexed: 02/04/2023] Open
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de Lange C, Reichert MJE, Pagano JJ, Seed M, Yoo SJ, Broberg CS, Lam CZ, Grosse-Wortmann L. Increased extracellular volume in the liver of pediatric Fontan patients. J Cardiovasc Magn Reson 2019; 21:39. [PMID: 31303178 PMCID: PMC6628496 DOI: 10.1186/s12968-019-0545-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 05/28/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Patients with single ventricle physiology are at increased risk for developing liver fibrosis. Its extent and prevalence in children with bidirectional cavopulmonary connection (BCPC) and Fontan circulation are unclear. Extracellular volume fraction (ECV), derived from cardiovascular magnetic resonance (CMR) and T1 relaxometry, reflect fibrotic remodeling and/or congestion in the liver. The aim of this study was to investigate whether pediatric patients with single ventricle physiology experience increased native T1 and ECV as markers of liver fibrosis/congestion. METHODS Hepatic native T1 times and ECV, using a cardiac short axis modified Look-Locker inversion recovery sequence displaying the liver, were measured retrospectively in children with BCPC- and Fontan circulations and compared to pediatric controls. RESULTS Hepatic native T1 time were increased in Fontan patients (n = 62, 11.4 ± 4.4 years, T1 762 ± 64 ms) versus BCPC patients (n = 20, 2.8 ± 0.9 years, T1 645 ± 43 ms, p = 0.04). Both cohorts had higher T1 than controls (n = 44, 13.7 ± 2.9 years, T1 604 ± 54 ms, p < 0.001 for both). ECV was 41.4 ± 4.8% in Fontan and 36.4 ± 4.8% in BCPC patients, respectively (p = 0.02). In Fontan patients, T1 values correlated with exposure to cardiopulmonary bypass time (R = 0.3, p = 0.02), systolic and end diastolic volumes (R = 0.3, p = 0.04 for both) and inversely with oxygen saturations and body surface area (R = -0.3, p = 0.04 for both). There were no demonstrable associations of T1 or ECV with central venous pressure or age after Fontan. CONCLUSION Fontan and BCPC patients have elevated CMR markers suggestive of hepatic fibrosis and/or congestion, even at a young age. The tissue changes do not appear to be related to central venous pressures. TRIAL REGISTRATION Retrospectively registered data.
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Affiliation(s)
- Charlotte de Lange
- Department of Pediatrics, Division of Cardiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada
- Division of Radiology and Nuclear medicine, Pediatric section, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Marjolein J. E. Reichert
- Department of Pediatrics, Division of Cardiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Joseph J. Pagano
- Department of Pediatrics, Division of Cardiology, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta Canada
| | - Mike Seed
- Department of Pediatrics, Division of Cardiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario Canada
| | - Shi-Joon Yoo
- Department of Pediatrics, Division of Cardiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario Canada
| | - Craig S. Broberg
- Knight Cardiovascular Institute, Division of Cardiovascular Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Christopher Z. Lam
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario Canada
| | - Lars Grosse-Wortmann
- Department of Pediatrics, Division of Cardiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario Canada
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Komatsu H, Inui A, Kishiki K, Kawai H, Yoshio S, Osawa Y, Kanto T, Fujisawa T. Liver disease secondary to congenital heart disease in children. Expert Rev Gastroenterol Hepatol 2019; 13:651-666. [PMID: 31131680 DOI: 10.1080/17474124.2019.1621746] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Hepatic fibrosis and hepatocellular carcinoma (HCC) can develop in children with congenital heart disease. Although hepatic fibrosis and HCC are prone to develop after the Fontan operation, they can also develop in patients suffering from congenital heart disease who have not undergone Fontan operation. Area covered: The history of cardiac hepatopathy including Fontan-associated liver disease is described. Patient characteristics, liver histology, imaging examinations and blood tests are reviewed to elucidate the mechanism of cardiac hepatopathy. In addition, a flowchart for the follow-up management of cardiac hepatopathy in children with congenital heart disease is proposed. Expert opinion: Congestion and low cardiac output are the main causes of cardiac hepatopathy. Advanced hepatic fibrosis is presumed to be associated with HCC. HCC can develop in both adolescents and young adults. Regardless of whether the Fontan operation is performed, children with a functional single ventricle and chronic heart failure should be regularly examined for cardiac hepatopathy. There is no single reliable laboratory parameter to accurately detect cardiac hepatopathy; hepatic fibrosis indices and elastography have shown inconsistent results for detection of this disease. Further studies using liver specimen-confirmed patients and standardization of evaluation protocols are required to clarify the pathogenesis of cardiac hepatopathy.
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Affiliation(s)
- Haruki Komatsu
- a Department of Pediatrics , Toho University, Sakura Medical Center , Chiba , Japan
| | - Ayano Inui
- b Department of Pediatric Hepatology and Gastroenterology , Eastern Yokohama Hospital , Kanagawa , Japan
| | - Kanako Kishiki
- c Department of Pediatric Cardiology , Sakakibara Heart Institute , Tokyo , Japan
| | - Hironari Kawai
- d Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine , Chiba , Japan
| | - Sachiyo Yoshio
- d Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine , Chiba , Japan
| | - Yosuke Osawa
- d Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine , Chiba , Japan
| | - Tatsuya Kanto
- d Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine , Chiba , Japan
| | - Tomoo Fujisawa
- b Department of Pediatric Hepatology and Gastroenterology , Eastern Yokohama Hospital , Kanagawa , Japan
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Assessment of liver T1 mapping in fontan patients and its correlation with magnetic resonance elastography-derived liver stiffness. Abdom Radiol (NY) 2019; 44:2403-2408. [PMID: 30903232 DOI: 10.1007/s00261-019-01990-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES To explore the utility of liver T1 mapping in Fontan patients and its correlation to magnetic resonance elastography (MRE)-derived liver stiffness. BACKGROUND AND AIMS Liver disease is a major long-term extra cardiac complication in the Fontan population. MRE is frequently used to quantify liver stiffness in Fontan patients; however, it has certain limitations. Native T1 mapping by cardiac magnetic resonance (CMR) is useful in assessment of cardiac fibrosis, but its potential in evaluating liver fibrosis and its correlation to MRE-derived liver stiffness in Fontan patients have not been reported. METHODS Fontan patients who underwent CMR and MRE were included. Liver Native T1, extracellular volume (ECV) and delta coefficients were measured and correlated with MRE-derived liver stiffness in all Fontan patients. Native liver T1 in Fontan patients were compared to normal controls with biventricular circulation and no known liver disease. RESULTS A total of 17 Fontan patients and 7 normal controls were included in this study. Fontan patients had significantly higher liver native T1 (690 ± 41 ms vs 620 ± 35 ms; p < 0.001) as compared to controls. There was strong positive correlation between MRE derived liver stiffness and liver native T1 (r = 0.81, p < 0.001). CONCLUSIONS Liver native T1 was significantly elevated in Fontan patients compared to controls and strongly correlated with MRE-derived liver stiffness. This technique may prove to be a useful noninvasive imaging biomarker for assessing liver fibrosis in the Fontan population.
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Magnetic resonance elastography SE-EPI vs GRE sequences at 3T in a pediatric population with liver disease. Abdom Radiol (NY) 2019; 44:894-902. [PMID: 30600386 DOI: 10.1007/s00261-018-1884-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE The goal of our study is to compare hepatic stiffness measures using gradient-recalled echo (GRE) versus spin-echo echo planar imaging (SE-EPI)-based MR Elastography (MRE) at 3T used to measure hepatic stiffness in a patients with suspected liver diseases. MATERIALS AND METHODS This retrospective study included 52 patients with liver disease who underwent a 3T MRE exam including both an investigational SE-EPI-based technique and a product GRE-based technique. Regions of interest (ROI) were placed on the elastograms to measure elastography-derived liver stiffness as well as the area included within the ROIs. The mean liver stiffness values and area of ROIs were compared. RESULTS The mean liver stiffness was 3.72 kilopascal (kPa) ± 1.29 using GRE MRE and 3.78 kPa ± 1.13 using SE-EPI MRE. Measurement of liver stiffness showed excellent agreement between the two pulse sequences with a mean bias of - 0.1 kPa (range - 1.8 to 1.7 kPa) between sequences. The mean measurable ROI area was higher with SE-EPI (313.8 cm2 ± 213.8) than with the GRE technique (208.6 cm2 ± 114.8), and the difference was statistically significant (P < 0.05). CONCLUSIONS Our data shows excellent agreement of measured liver stiffness between GRE and SE-EPI-based sequences at 3T. Our results show the advantage of a SE-EPI MRE sequence in terms of image quality, ROI size and acquisition time with equivalent liver stiffness measurements as compared to GRE-MRE sequence.
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Srinivasan A, Guzman AK, Rand EB, Rychik J, Goldberg DJ, Russo PA, Cahill AM. Percutaneous liver biopsy in Fontan patients. Pediatr Radiol 2019; 49:342-350. [PMID: 30506328 DOI: 10.1007/s00247-018-4311-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 10/06/2018] [Accepted: 11/09/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Patients who have undergone the Fontan operation for palliation of congenital heart disease with single-ventricle pathophysiology are at high risk for developing progressive liver fibrosis. Pathological assessment from percutaneous liver biopsy is central to the management of Fontan-associated liver disease, but liver biopsy in this vulnerable population poses unique challenges and potential risks. OBJECTIVE This retrospective study describes our experience with percutaneous liver biopsy performed to assess changes of Fontan-associated liver disease, with particular regard to procedural outcomes. MATERIALS AND METHODS Data from liver biopsy procedure reports, pathology reports, cardiac angiography pressure measurements and laboratory values of patients with single ventricle heart disease after the Fontan operation who underwent ultrasound-guided percutaneous liver biopsy performed in interventional radiology at a pediatric tertiary care center during a 3-year period were retrospectively analyzed. RESULTS Sixty-eight liver biopsies were performed in 67 patients (mean age: 20.2 years, range: 7.2-39 years). The technical success rate was 100%, and tissue was adequate for assessing liver disease in 100% of the procedures, including biopsies performed with a single pass. Anticoagulation was routinely suspended before biopsy, and no cardiac complications were encountered due to this suspension. A coaxial biopsy system using an 18-gauge (G) full-core instrument through a 17-G introducer trocar was most commonly used, in 41/68 cases (60%). The most common trough length was 2.3 cm, used in 37 cases (54%). One pass was made in 27 procedures (40%) and two passes in 30 (44%); tract embolization with gelatin sponge was performed in 52 (76%). The only complication was hemorrhage, which occurred in 5/68 (7.4%) of the biopsies, minor in four (5.9%) and major in one (1.5%) -- similar to rates reported for liver biopsy in non-Fontan patients. Hemorrhage had a delayed presentation in three of these five cases. Immediate post-biopsy hemoglobin decrease of ≥2 mg/dL showed a low sensitivity for hemorrhage. The mean Fontan pressure measured during cardiac angiography was 13.8 mmHg, and shunt pressures were not associated with an increased risk of hemorrhage. CONCLUSION Percutaneous liver biopsy in Fontan patients can be performed safely with high technical success rates and without increased complication rates. Meticulous technique and close observation are recommended to reduce post-biopsy complications. The degree of right heart pressure elevation was not associated with hemorrhage.
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Affiliation(s)
- Abhay Srinivasan
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Radiology 3NW47, Philadelphia, PA, 19104, USA. .,Children Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, USA.
| | - Anthony K Guzman
- Children Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, USA
| | - Elizabeth B Rand
- Children Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, USA.,Department of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jack Rychik
- Children Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, USA.,Department of Cardiology, University of Pennsylvania Peralman School of Medicine, Philadelphia, PA, USA
| | - David J Goldberg
- Children Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, USA.,Department of Cardiology, University of Pennsylvania Peralman School of Medicine, Philadelphia, PA, USA
| | - Pierre A Russo
- Children Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, USA.,Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Anne Marie Cahill
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Radiology 3NW47, Philadelphia, PA, 19104, USA.,Children Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, USA
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Kazour I, Serai SD, Xanthakos SA, Fleck RJ. Using T1 mapping in cardiovascular magnetic resonance to assess congestive hepatopathy. Abdom Radiol (NY) 2018; 43:2679-2685. [PMID: 29500649 PMCID: PMC6120811 DOI: 10.1007/s00261-018-1528-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The goal of this study was to assess the ability of quantitative T1 cardiovascular magnetic resonance (CMR) imaging to calculate liver extracellular volume (ECV) in patients with varying degrees of congestive hepatopathy (CH). T1 measurements and ECV calculations were performed retrospectively in three cohorts of patients: normal cardiac function, tetralogy of fallot (TOF) repair and Fontan palliation. All CMR studies included modified look-locker inversion recovery (MOLLI) T1 mapping scans performed pre- and post-injection of a gadolinium-based contrast agent (GBCA). Pixel intensity data were manually collected from images of the liver and cardiac blood pool to determine contrast-induced changes in T1 for liver and blood. These data were then used to compute liver ECV. 172 subjects were included in the study. Of these, 140 subjects were normal cardiac function patients, 16 were TOF repair patients and 16 patients were with Fontan palliation. A statistically significant difference in both the liver native T1 and ECV measurements was found between patients with normal cardiac function vs. Fontan palliation patients (p < 0.01). Our data indicate that measuring T1 maps both pre- and post-GBCA injection within CMR scan session can be used to follow progression of liver fibrosis. This technique has the potential to improve diagnosis and treatment of patients with chronic liver disease and liver fibrosis.
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Affiliation(s)
- Isabel Kazour
- Department of Radiology, MLC 5031, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Nutritional Biochemistry and Metabolism, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH, 44106, USA
| | - Suraj D Serai
- Department of Radiology, MLC 5031, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Stavra A Xanthakos
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Robert J Fleck
- Department of Radiology, MLC 5031, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
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Fovargue D, Nordsletten D, Sinkus R. Stiffness reconstruction methods for MR elastography. NMR IN BIOMEDICINE 2018; 31:e3935. [PMID: 29774974 PMCID: PMC6175248 DOI: 10.1002/nbm.3935] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 03/27/2018] [Accepted: 03/27/2018] [Indexed: 05/19/2023]
Abstract
Assessment of tissue stiffness is desirable for clinicians and researchers, as it is well established that pathophysiological mechanisms often alter the structural properties of tissue. Magnetic resonance elastography (MRE) provides an avenue for measuring tissue stiffness and has a long history of clinical application, including staging liver fibrosis and stratifying breast cancer malignancy. A vital component of MRE consists of the reconstruction algorithms used to derive stiffness from wave-motion images by solving inverse problems. A large range of reconstruction methods have been presented in the literature, with differing computational expense, required user input, underlying physical assumptions, and techniques for numerical evaluation. These differences, in turn, have led to varying accuracy, robustness, and ease of use. While most reconstruction techniques have been validated against in silico or in vitro phantoms, performance with real data is often more challenging, stressing the robustness and assumptions of these algorithms. This article reviews many current MRE reconstruction methods and discusses the aforementioned differences. The material assumptions underlying the methods are developed and various approaches for noise reduction, regularization, and numerical discretization are discussed. Reconstruction methods are categorized by inversion type, underlying assumptions, and their use in human and animal studies. Future directions, such as alternative material assumptions, are also discussed.
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Affiliation(s)
- Daniel Fovargue
- Imaging Sciences & Biomedical EngineeringKing's College LondonLondonUK
| | - David Nordsletten
- Imaging Sciences & Biomedical EngineeringKing's College LondonLondonUK
| | - Ralph Sinkus
- Imaging Sciences & Biomedical EngineeringKing's College LondonLondonUK
- Inserm U1148, LVTSUniversity Paris Diderot, University Paris 13Paris75018France
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Schachter JL, Patel M, Horton SR, Mike Devane A, Ewing A, Abrams GA. FibroSURE and elastography poorly predict the severity of liver fibrosis in Fontan-associated liver disease. CONGENIT HEART DIS 2018; 13:764-770. [PMID: 30101472 DOI: 10.1111/chd.12650] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/24/2018] [Accepted: 06/10/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVE As the population of patients with Fontan circulation surviving into adulthood increases, hepatic cirrhosis has grown to be a significant cause of morbidity and mortality. Early detection of advanced hepatic fibrosis is imperative for proper intervention and consideration for heart or combined heart/liver transplantation. Noninvasive biomarkers and elastography have been evaluated for their diagnostic utility with variable results in the Fontan population. DESIGN The cohort included 14 patients age 26.4 SD 7.5 who underwent Fontan surgery. All patients were evaluated with FibroSURE, shear wave elastography (SWE), hepatic duplex sonography, and liver biopsy. Liver fibrosis on biopsy was evaluated according to the congestive hepatic fibrosis system. RESULTS In our cohort, 100% of patients had fibrosis with 36% demonstrating advanced fibrosis. FibroSURE agreed with liver biopsy in only 5 out of 14 cases (36%): underestimating in 7 and overestimating in 2 individuals. SWE agreed with liver biopsy in 0% of cases: overestimating in 10 and underestimating in 4 cases. None of the duplex sonography indices predicted the presence or severity of liver fibrosis. CONCLUSION This study demonstrates that children who have undergone a Fontan procedure universally develop some hepatic fibrosis and a significant number have advanced fibrosis by adulthood. The FibroSURE blood test, SWE, and hepatic duplex sonography were unable to accurately predict the presence or severity of hepatic fibrosis when compared with liver biopsy. Further studies are needed to investigate novel noninvasive methods and/or biomarkers that can adequately detect advanced hepatic fibrosis before the development of cirrhosis and hepatic decompensation.
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Affiliation(s)
- Jessica L Schachter
- Department of Medicine, Greenville Memorial Hospital, Greenville, South Carolina
| | - Manisha Patel
- Department of Cardiology, Greenville Memorial Hospital, Greenville, South Carolina
| | - Samuel R Horton
- Department of Pathology, Greenville Memorial Hospital, Greenville, South Carolina
| | - A Mike Devane
- Department of Radiology, Greenville Memorial Hospital, Greenville, South Carolina
| | - Alex Ewing
- Department of Quality, Greenville Memorial Hospital, Greenville, South Carolina
| | - Gary A Abrams
- Department of Gastroenterology, Greenville Memorial Hospital, Greenville, South Carolina
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Serai SD, Trout AT, Miethke A, Diaz E, Xanthakos SA, Dillman JR. Putting it all together: established and emerging MRI techniques for detecting and measuring liver fibrosis. Pediatr Radiol 2018; 48:1256-1272. [PMID: 30078038 DOI: 10.1007/s00247-018-4083-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 10/21/2017] [Accepted: 01/16/2018] [Indexed: 12/17/2022]
Abstract
Chronic injury to the liver leads to inflammation and hepatocyte necrosis, which when untreated can lead to myofibroblast activation and fibrogenesis with deposition of fibrous tissue. Over time, liver fibrosis can accumulate and lead to cirrhosis and end-stage liver disease with associated portal hypertension and liver failure. Detection and accurate measurement of the severity of liver fibrosis are important for assessing disease severity and progression, directing patient management, and establishing prognosis. Liver biopsy, generally considered the clinical standard of reference for detecting and measuring liver fibrosis, is invasive and has limitations, including sampling error, relatively high cost, and possible complications. For these reasons, liver biopsy is suboptimal for fibrosis screening, longitudinal monitoring, and assessing therapeutic efficacy. A variety of established and emerging qualitative and quantitative noninvasive MRI methods for detecting and staging liver fibrosis might ultimately serve these purposes. In this article, we review multiple MRI methods for detecting and measuring liver fibrosis and discuss the diagnostic performance and specific strengths and limitations of the various techniques.
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Affiliation(s)
- Suraj D Serai
- Department of Radiology, MLC 5031, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA. .,Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Andrew T Trout
- Department of Radiology, MLC 5031, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA
| | - Alexander Miethke
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Eric Diaz
- Department of Radiology, MLC 5031, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA
| | - Stavra A Xanthakos
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jonathan R Dillman
- Department of Radiology, MLC 5031, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA
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Egbe A, Miranda WR, Connolly HM, Khan AR, Al-Otaibi M, Venkatesh SK, Simonetto D, Kamath P, Warnes C. Temporal changes in liver stiffness after Fontan operation: Results of serial magnetic resonance elastography. Int J Cardiol 2018; 258:299-304. [DOI: 10.1016/j.ijcard.2018.01.108] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 12/17/2017] [Accepted: 01/22/2018] [Indexed: 12/27/2022]
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Daniels CJ, Bradley EA, Landzberg MJ, Aboulhosn J, Beekman RH, Book W, Gurvitz M, John A, John B, Marelli A, Marino BS, Minich LL, Poterucha JJ, Rand EB, Veldtman GR. Fontan-Associated Liver Disease. J Am Coll Cardiol 2017; 70:3173-3194. [DOI: 10.1016/j.jacc.2017.10.045] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Buendía-Fuentes F, Melero-Ferrer JL, Plaza-López D, Rueda-Soriano J, Osa-Saez A, Aguero J, Calvillo-Batllés P, Fonfria-Esparcia C, Ballesta-Cuñat A, Martí-Bonmatí L, Martínez-Dolz L. Noninvasive Liver Assessment in Adult Patients With Fontan Circulation Using Acoustic Radiation Force Impulse Elastography and Hepatic Magnetic Resonance Imaging. World J Pediatr Congenit Heart Surg 2017; 9:22-30. [PMID: 29103357 DOI: 10.1177/2150135117732674] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Patients who have undergone the Fontan procedure are at risk of developing hepatic dysfunction. However, broad recommendations regarding liver monitoring are limited. The purpose of this study was to characterize the frequency of liver disease in adult Fontan patients using multimodality imaging (hepatic magnetic resonance imaging [MRI], acoustic radiation force impulse [ARFI] elastography, or hepatic ultrasound). METHODS In a prospective cross-sectional analysis of adult patients palliated with a Fontan procedure, hepatic MRI, ARFI, and hepatic ultrasound were used to assess for liver disease. The protocol compared (1) varying prevalence of liver disease based on each imaging technique, (2) agreement between different techniques, and (3) association between noninvasive imaging diagnosis of liver disease and clinical variables, including specific liver disease biomarkers. RESULTS Thirty-seven patients were enrolled. The ARFI results showed high wave propagation velocity in 35 patients (94.6%). All patients had some abnormality in the hepatic MRI. Specifically, 8 patients (21.6%) showed signs of chronic liver disease, 10 patients (27%) had significant liver fibrosis, and 27 patients (73%) had congestion. No correlation was found between liver stiffness measured as propagation velocity and hepatic MRI findings. Only 7 patients had an abnormal hepatic ultrasound study. CONCLUSIONS There is an inherent liver injury in adult Fontan patients. Signs of liver disease were observed in most patients by both hepatic MRI and ARFI elastography but not by ultrasound imaging. Increased liver stiffness did not identify specific disease patterns from MRI, supporting the need for multimodality imaging to characterize liver disease in Fontan patients.
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Affiliation(s)
- F Buendía-Fuentes
- 1 Department of Cardiology, Arnau de Vilanova Hospital, Valencia, Spain
| | - J L Melero-Ferrer
- 2 Adult Congenital Heart Disease Unit, Department of Cardiology, La Fe University Hospital, Valencia, Spain
| | - D Plaza-López
- 2 Adult Congenital Heart Disease Unit, Department of Cardiology, La Fe University Hospital, Valencia, Spain
| | - J Rueda-Soriano
- 2 Adult Congenital Heart Disease Unit, Department of Cardiology, La Fe University Hospital, Valencia, Spain
| | - A Osa-Saez
- 2 Adult Congenital Heart Disease Unit, Department of Cardiology, La Fe University Hospital, Valencia, Spain
| | - J Aguero
- 2 Adult Congenital Heart Disease Unit, Department of Cardiology, La Fe University Hospital, Valencia, Spain
| | | | | | - A Ballesta-Cuñat
- 4 Department of Hepatology, La Fe University Hospital, Valencia, Spain
| | - L Martí-Bonmatí
- 3 Department of Radiology, La Fe University Hospital, Valencia, Spain
| | - L Martínez-Dolz
- 2 Adult Congenital Heart Disease Unit, Department of Cardiology, La Fe University Hospital, Valencia, Spain
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Yang C, Yin M, Glaser KJ, Zhu X, Xu K, Ehman RL, Chen J. Static and dynamic liver stiffness: An ex vivo porcine liver study using MR elastography. Magn Reson Imaging 2017; 44:92-95. [PMID: 28866387 DOI: 10.1016/j.mri.2017.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 08/10/2017] [Accepted: 08/30/2017] [Indexed: 01/26/2023]
Abstract
Magnetic resonance elastography (MRE) is an MRI-based noninvasive technique for quantitatively assessing tissue stiffness. The hypothesis of this study is that stiffness increases with portal pressure. We further hypothesized that the rate of stiffness change with pressure would be larger in liver tissue treated to simulate the stiffening effects of fibrosis. In agreement with our hypothesis, the formalin-treated livers were stiffer than the untreated livers, and in both groups the liver stiffness increased with portal venous pressure. The rate of stiffness change with portal pressure was significantly greater after formalin treatment. In this study, we have developed an ex vivo liver model incorporating portal venous pressure variations and observed significant changes in liver stiffness due to portal pressure. This model could be useful for understanding and investigating the changes in the static and dynamic components of liver stiffness.
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Affiliation(s)
- Chun Yang
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA; Department of Radiology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huai-hai Road, Xuzhou, Jiangsu 221002, PR China
| | - Meng Yin
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Kevin J Glaser
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Xiangyang Zhu
- Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Kai Xu
- Department of Radiology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huai-hai Road, Xuzhou, Jiangsu 221002, PR China
| | - Richard L Ehman
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Jun Chen
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Serai SD, Obuchowski NA, Venkatesh SK, Sirlin CB, Miller FH, Ashton E, Cole PE, Ehman RL. Repeatability of MR Elastography of Liver: A Meta-Analysis. Radiology 2017; 285:92-100. [PMID: 28530847 DOI: 10.1148/radiol.2017161398] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Purpose To perform a meta-analysis to generate an estimate of the repeatability coefficient (RC) for magnetic resonance (MR) elastography of the liver. Materials and Methods A systematic search of databases was performed for publications on MR elastography during the 10-year period between 2006 and 2015. The identified studies were screened independently and were verified reciprocally by all authors. Two reviewers independently determined the percentage RC and effective sample size from each article. A forest plot was constructed of the percentage RC estimates from the 12 studies. Bootstrap 95% confidence intervals (CIs) were constructed for the summary percentage RCs. Results Twelve studies comprising 274 patients met the eligibility criteria and were included for analysis. A flow diagram of studies included according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was prepared for the inclusion and exclusion criteria. All studies included in the meta-analysis fulfilled four or more of the seven categories of the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2. The estimated summary RC was 22% (95% CI: 16.1%, 28.2%). The three main sources for this heterogeneity were the trained versus untrained operator drawing contours to choose regions of interest, the time between two replicate examinations, and, finally, the field strength of the MR imaging unit. The RC estimates tended to be higher for studies that did not use a well-trained operator, those with 1.5-T field strength imaging units, and those with longer time intervals between examinations. Conclusion The meta-analysis results provide the basis for the following draft longitudinal Quantitative Imaging Biomarkers Alliance MR elastography claim: A measured change in hepatic stiffness of 22% or greater, at the same site and with use of the same equipment and acquisition sequence, indicates that a true change in stiffness has occurred with 95% confidence. © RSNA, 2017.
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Affiliation(s)
- Suraj D Serai
- From the Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 5031, Cincinnati, OH 45229 (S.D.S.); Department of Quantitative Health Sciences, the Cleveland Clinic Foundation, Cleveland, Ohio (N.A.O.); Department of Radiology, Mayo Clinic, Rochester, Minn (S.K.V., R.L.E.); Department of Radiology, UCSD Liver Imaging Group, San Diego, Calif (C.B.S.); Department of Radiology, Northwestern Memorial Hospital, Chicago, Ill (F.H.M.); Virtualscopics, Rochester, NY (E.A.); and Clinical and Translational Science-Imaging, Takeda Pharmaceuticals, Deerfield, Ill (P.E.C.)
| | - Nancy A Obuchowski
- From the Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 5031, Cincinnati, OH 45229 (S.D.S.); Department of Quantitative Health Sciences, the Cleveland Clinic Foundation, Cleveland, Ohio (N.A.O.); Department of Radiology, Mayo Clinic, Rochester, Minn (S.K.V., R.L.E.); Department of Radiology, UCSD Liver Imaging Group, San Diego, Calif (C.B.S.); Department of Radiology, Northwestern Memorial Hospital, Chicago, Ill (F.H.M.); Virtualscopics, Rochester, NY (E.A.); and Clinical and Translational Science-Imaging, Takeda Pharmaceuticals, Deerfield, Ill (P.E.C.)
| | - Sudhakar K Venkatesh
- From the Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 5031, Cincinnati, OH 45229 (S.D.S.); Department of Quantitative Health Sciences, the Cleveland Clinic Foundation, Cleveland, Ohio (N.A.O.); Department of Radiology, Mayo Clinic, Rochester, Minn (S.K.V., R.L.E.); Department of Radiology, UCSD Liver Imaging Group, San Diego, Calif (C.B.S.); Department of Radiology, Northwestern Memorial Hospital, Chicago, Ill (F.H.M.); Virtualscopics, Rochester, NY (E.A.); and Clinical and Translational Science-Imaging, Takeda Pharmaceuticals, Deerfield, Ill (P.E.C.)
| | - Claude B Sirlin
- From the Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 5031, Cincinnati, OH 45229 (S.D.S.); Department of Quantitative Health Sciences, the Cleveland Clinic Foundation, Cleveland, Ohio (N.A.O.); Department of Radiology, Mayo Clinic, Rochester, Minn (S.K.V., R.L.E.); Department of Radiology, UCSD Liver Imaging Group, San Diego, Calif (C.B.S.); Department of Radiology, Northwestern Memorial Hospital, Chicago, Ill (F.H.M.); Virtualscopics, Rochester, NY (E.A.); and Clinical and Translational Science-Imaging, Takeda Pharmaceuticals, Deerfield, Ill (P.E.C.)
| | - Frank H Miller
- From the Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 5031, Cincinnati, OH 45229 (S.D.S.); Department of Quantitative Health Sciences, the Cleveland Clinic Foundation, Cleveland, Ohio (N.A.O.); Department of Radiology, Mayo Clinic, Rochester, Minn (S.K.V., R.L.E.); Department of Radiology, UCSD Liver Imaging Group, San Diego, Calif (C.B.S.); Department of Radiology, Northwestern Memorial Hospital, Chicago, Ill (F.H.M.); Virtualscopics, Rochester, NY (E.A.); and Clinical and Translational Science-Imaging, Takeda Pharmaceuticals, Deerfield, Ill (P.E.C.)
| | - Edward Ashton
- From the Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 5031, Cincinnati, OH 45229 (S.D.S.); Department of Quantitative Health Sciences, the Cleveland Clinic Foundation, Cleveland, Ohio (N.A.O.); Department of Radiology, Mayo Clinic, Rochester, Minn (S.K.V., R.L.E.); Department of Radiology, UCSD Liver Imaging Group, San Diego, Calif (C.B.S.); Department of Radiology, Northwestern Memorial Hospital, Chicago, Ill (F.H.M.); Virtualscopics, Rochester, NY (E.A.); and Clinical and Translational Science-Imaging, Takeda Pharmaceuticals, Deerfield, Ill (P.E.C.)
| | - Patricia E Cole
- From the Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 5031, Cincinnati, OH 45229 (S.D.S.); Department of Quantitative Health Sciences, the Cleveland Clinic Foundation, Cleveland, Ohio (N.A.O.); Department of Radiology, Mayo Clinic, Rochester, Minn (S.K.V., R.L.E.); Department of Radiology, UCSD Liver Imaging Group, San Diego, Calif (C.B.S.); Department of Radiology, Northwestern Memorial Hospital, Chicago, Ill (F.H.M.); Virtualscopics, Rochester, NY (E.A.); and Clinical and Translational Science-Imaging, Takeda Pharmaceuticals, Deerfield, Ill (P.E.C.)
| | - Richard L Ehman
- From the Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 5031, Cincinnati, OH 45229 (S.D.S.); Department of Quantitative Health Sciences, the Cleveland Clinic Foundation, Cleveland, Ohio (N.A.O.); Department of Radiology, Mayo Clinic, Rochester, Minn (S.K.V., R.L.E.); Department of Radiology, UCSD Liver Imaging Group, San Diego, Calif (C.B.S.); Department of Radiology, Northwestern Memorial Hospital, Chicago, Ill (F.H.M.); Virtualscopics, Rochester, NY (E.A.); and Clinical and Translational Science-Imaging, Takeda Pharmaceuticals, Deerfield, Ill (P.E.C.)
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Goldberg DJ, Surrey LF, Glatz AC, Dodds K, O'Byrne ML, Lin HC, Fogel M, Rome JJ, Rand EB, Russo P, Rychik J. Hepatic Fibrosis Is Universal Following Fontan Operation, and Severity is Associated With Time From Surgery: A Liver Biopsy and Hemodynamic Study. J Am Heart Assoc 2017; 6:JAHA.116.004809. [PMID: 28446492 PMCID: PMC5524062 DOI: 10.1161/jaha.116.004809] [Citation(s) in RCA: 173] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background Congestive hepatopathy is a recognized complication of Fontan physiology. Data regarding the incidence of hepatopathy and risk factors are lacking. Methods and Results Liver biopsies and cardiac catherizations were performed as part of an evaluation offered to all patients ≥10 years after Fontan. Quantitative determination of hepatic fibrosis was performed using Sirius red staining with automated calculation of collagen deposition per slide (%CD). Biopsies from included subjects were compared to stained specimens from controls without known fibrotic liver disease. Patient characteristics, echocardiographic findings, and hemodynamic measures were evaluated as potential risk factors. The cohort consisted of 67 patients (31 female) at mean age of 17.3±4.5 years and mean time from Fontan of 14.9±4.5 years. Right ventricular morphology was present in 37 subjects. Median %CD by Sirius red staining was 21.6% (range 8.7% to 49.4%) compared to 2.6% (range 2.2% to 3.0%) in controls. There was a significant correlation between time from Fontan and degree of Sirius red staining (r=0.33, P<0.01). Serum liver enzymes and platelet count did not correlate with %CD. The median inferior vena cava pressure was 13 mm Hg (range 6‐24 mm Hg) and did not correlate with %CD. There was no difference in %CD based on ventricular morphology or severity of atrioventricular valve insufficiency. Conclusions In this cohort of predominantly asymptomatic children and adolescents electively evaluated after a Fontan operation, all exhibited evidence for hepatic fibrosis as measured by collagen deposition in the liver. Time from Fontan was the only factor significantly associated with collagen deposition. These findings demonstrate that liver fibrosis is an inherent feature of Fontan physiology and that the degree of fibrosis increases over time.
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Affiliation(s)
- David J Goldberg
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lea F Surrey
- Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Andrew C Glatz
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kathryn Dodds
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Henry C Lin
- Division of Gastroenterology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mark Fogel
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jonathan J Rome
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Elizabeth B Rand
- Division of Gastroenterology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Pierre Russo
- Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jack Rychik
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Fidai A, Dallaire F, Alvarez N, Balon Y, Clegg R, Connelly M, Dicke F, Fruitman D, Harder J, Myers K, Patton DJ, Prieur T, Vorhies E, Myers RP, Martin SR, Greenway SC. Non-invasive Investigations for the Diagnosis of Fontan-Associated Liver Disease in Pediatric and Adult Fontan Patients. Front Cardiovasc Med 2017; 4:15. [PMID: 28396861 PMCID: PMC5366328 DOI: 10.3389/fcvm.2017.00015] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 03/09/2017] [Indexed: 12/18/2022] Open
Abstract
Fontan-associated liver disease (FALD) is a serious complication related to the chronically elevated venous pressure and low cardiac output of this abnormal circulation. However, diagnostic markers for this condition are limited. We hypothesized that specific tests for fibrosis developed for other chronic liver diseases would identify a higher prevalence of FALD than ultrasound and standard laboratory tests and that identified abnormalities would correlate with time post-Fontan. In this cross-sectional study, we assessed 19 children (average age 8.4 ± 4.3 and 5.4 ± 4.1 years post-Fontan) and 8 adults (average age 31.5 ± 8.9 and 21.1 ± 4 years post-Fontan) using standard serum laboratory investigations assessing hepatic integrity and function, the FibroTest, liver ultrasound, and transient elastography (FibroScan). In adult Fontan patients, hemoglobin, C-reactive protein, and gamma-glutamyl transpeptidase were significantly increased, and white blood cell and platelet counts were significantly decreased in comparison to the pediatric cohort. International normalized ratio was mildly elevated in both children and adults. FibroTest results were suggestive of fibrosis regardless of time post-Fontan. FibroScan measurements were significantly correlated with time post-Fontan, but the incidence of ultrasound-detected liver abnormalities was variable. No cases of hepatocellular carcinoma were identified. Abnormalities suggestive of FALD occur in both children and adults post-Fontan. Select laboratory tests, and possibly ultrasound and FibroScan in some patients, appear to have the most promise for the non-invasive detection of FALD.
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Affiliation(s)
- Amyna Fidai
- Department of Paediatrics, Cumming School of Medicine, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Frederic Dallaire
- Division of Pediatric Cardiology, University of Sherbrooke, Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Nanette Alvarez
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Yvonne Balon
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Robin Clegg
- Department of Paediatrics, Cumming School of Medicine, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Michael Connelly
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Frank Dicke
- Department of Paediatrics, Cumming School of Medicine, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Deborah Fruitman
- Department of Paediatrics, Cumming School of Medicine, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Joyce Harder
- Department of Paediatrics, Cumming School of Medicine, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Kimberley Myers
- Department of Paediatrics, Cumming School of Medicine, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - David J. Patton
- Department of Paediatrics, Cumming School of Medicine, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Tim Prieur
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Erika Vorhies
- Department of Paediatrics, Cumming School of Medicine, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Robert P. Myers
- Liver Unit, Division of Gastroenterology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Steven R. Martin
- Department of Paediatrics, Cumming School of Medicine, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Steven C. Greenway
- Department of Paediatrics, Cumming School of Medicine, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
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Serai SD, Dillman JR, Trout AT. Spin-echo Echo-planar Imaging MR Elastography versus Gradient-echo MR Elastography for Assessment of Liver Stiffness in Children and Young Adults Suspected of Having Liver Disease. Radiology 2017; 282:761-770. [DOI: 10.1148/radiol.2016160589] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Suraj D. Serai
- From the Department of Radiology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229
| | - Jonathan R. Dillman
- From the Department of Radiology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229
| | - Andrew T. Trout
- From the Department of Radiology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229
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40
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Serai SD, Trout AT, Sirlin CB. Elastography to assess the stage of liver fibrosis in children: Concepts, opportunities, and challenges. Clin Liver Dis (Hoboken) 2017; 9:5-10. [PMID: 30992948 PMCID: PMC6467133 DOI: 10.1002/cld.607] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 11/29/2016] [Indexed: 02/04/2023] Open
Affiliation(s)
| | | | - Claude B. Sirlin
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of MedicineCincinnatiOhio
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Hilscher MB, Johnson JN, Cetta F, Driscoll DJ, Poterucha JJ, Sanchez W, Connolly HM, Kamath PS. Surveillance for liver complications after the Fontan procedure. CONGENIT HEART DIS 2017; 12:124-132. [DOI: 10.1111/chd.12446] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 11/01/2016] [Accepted: 12/26/2016] [Indexed: 12/30/2022]
Affiliation(s)
- Moira B. Hilscher
- Department of Medicine/Division of Gastroenterology and Hepatology; Mayo Clinic; Rochester Minnesota USA
| | - Jonathan N. Johnson
- Department of Pediatrics and Adolescent Medicine/Division of Pediatric Cardiology; Mayo Clinic; Rochester Minnesota USA
- Department of Cardiovascular Diseases; Mayo Clinic; Rochester Minnesota USA
| | - Frank Cetta
- Department of Pediatrics and Adolescent Medicine/Division of Pediatric Cardiology; Mayo Clinic; Rochester Minnesota USA
- Department of Cardiovascular Diseases; Mayo Clinic; Rochester Minnesota USA
| | - David J. Driscoll
- Department of Pediatrics and Adolescent Medicine/Division of Pediatric Cardiology; Mayo Clinic; Rochester Minnesota USA
- Department of Cardiovascular Diseases; Mayo Clinic; Rochester Minnesota USA
| | - John J. Poterucha
- Department of Medicine/Division of Gastroenterology and Hepatology; Mayo Clinic; Rochester Minnesota USA
| | - William Sanchez
- Department of Medicine/Division of Gastroenterology and Hepatology; Mayo Clinic; Rochester Minnesota USA
| | - Heidi M. Connolly
- Department of Cardiovascular Diseases; Mayo Clinic; Rochester Minnesota USA
| | - Patrick S. Kamath
- Department of Medicine/Division of Gastroenterology and Hepatology; Mayo Clinic; Rochester Minnesota USA
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DiPaola FW, Schumacher KR, Goldberg CS, Friedland-Little J, Parameswaran A, Dillman JR. Effect of Fontan operation on liver stiffness in children with single ventricle physiology. Eur Radiol 2016; 27:2434-2442. [PMID: 27752831 DOI: 10.1007/s00330-016-4614-x] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 09/15/2016] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Assess liver stiffness using ultrasound point shear wave elastography (US P-SWE) in children before and after the Fontan operation. METHODS Eighteen children undergoing the Fontan operation were prospectively enrolled. Eight US P-SWE measurements were obtained from the right hepatic lobe before surgery, and at multiple postoperative time points. Temporally related inferior vena cava pressure (IVC) data was collected from medical records, when available. Changes in mean liver shear wave speed (SWS) were assessed using a mixed-effect model with post hoc Tukey correction. Changes in IVC pressure were evaluated using the Wilcoxon signed-rank test. A p value less than 0.05 was considered significant. RESULTS Mean age at enrolment was 33.5 ± 10.5 months. Baseline mean liver SWS was normal at 1.18 ± 0.29 m/s, increased to 2.28 ± 0.31 m/s at 2.5 ± 1.2 days (p < 0.0001) and to 2.22 ± 0.38 m/s at 7.5 ± 1.4 days (p < 0.0001). Five subjects returned at a mean of 185 ± 28 days, and mean liver SWS remained elevated at 2.08 ± 0.24 m/s (p < 0.0001). Mean IVC pressure increased from 7.2 ± 2.6 mmHg at baseline to 16.44 ± 3.3 mmHg at 2.2 ± 0.8 days post-surgery (p = 0.004). CONCLUSION The Fontan operation immediately and chronically increases liver stiffness and IVC pressure. Our study provides further evidence that congestion is a key driver of Fontan-associated liver disease. KEY POINTS • The Fontan operation triggers immediate hepatic congestion and marked liver stiffening. • Congestion, not fibrosis, drives early increased liver stiffness in Fontan patients. • Hepatic congestion persists chronically for months after the Fontan operation. • Congestion confounds shear wave elastography as a post-Fontan liver fibrosis biomarker.
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Affiliation(s)
- Frank W DiPaola
- Division of Pediatric Gastroenterology, Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Kurt R Schumacher
- Division of Pediatric Cardiology, Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Caren S Goldberg
- Division of Pediatric Cardiology, Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Joshua Friedland-Little
- Division of Pediatric Cardiology, Department of Pediatrics, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Aishwarya Parameswaran
- Michigan Institute for Clinical and Health Research (MICHR), University of Michigan, 2800 Plymouth Road, Building 400, Ann Arbor, MI, 48109, USA
| | - Jonathan R Dillman
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
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Non-invasive assessment of liver fibrosis by magnetic resonance elastography in patients with congenital heart disease undergoing the Fontan procedure and intracardiac repair. J Cardiol 2016; 68:202-8. [DOI: 10.1016/j.jjcc.2016.05.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 04/25/2016] [Accepted: 05/26/2016] [Indexed: 02/07/2023]
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Fontan circulation causes early, severe liver damage. Should we offer patients a tailored strategy? Int J Cardiol 2016; 209:60-5. [DOI: 10.1016/j.ijcard.2016.02.041] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 12/20/2015] [Accepted: 02/02/2016] [Indexed: 01/28/2023]
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45
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Bonnichsen C, Ammash N. Choosing Between MRI and CT Imaging in the Adult with Congenital Heart Disease. Curr Cardiol Rep 2016; 18:45. [DOI: 10.1007/s11886-016-0717-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Josephus Jitta D, Wagenaar LJ, Mulder BJ, Guichelaar M, Bouman D, van Melle JP. Three cases of hepatocellular carcinoma in Fontan patients: Review of the literature and suggestions for hepatic screening. Int J Cardiol 2016; 206:21-6. [DOI: 10.1016/j.ijcard.2015.12.033] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 12/31/2015] [Indexed: 01/08/2023]
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Gao Y, Erokwu BO, DeSantis DA, Croniger CM, Schur RM, Lu L, Mariappuram J, Dell KM, Flask CA. Initial evaluation of hepatic T1 relaxation time as an imaging marker of liver disease associated with autosomal recessive polycystic kidney disease (ARPKD). NMR IN BIOMEDICINE 2016; 29:84-9. [PMID: 26608869 PMCID: PMC4707433 DOI: 10.1002/nbm.3442] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 10/07/2015] [Accepted: 10/09/2015] [Indexed: 05/08/2023]
Abstract
Autosomal recessive polycystic kidney disease (ARPKD) is a potentially lethal multi-organ disease affecting both the kidneys and the liver. Unfortunately, there are currently no non-invasive methods to monitor liver disease progression in ARPKD patients, limiting the study of potential therapeutic interventions. Herein, we perform an initial investigation of T1 relaxation time as a potential imaging biomarker to quantitatively assess the two primary pathologic hallmarks of ARPKD liver disease: biliary dilatation and periportal fibrosis in the PCK rat model of ARPKD. T1 relaxation time results were obtained for five PCK rats at 3 months of age using a Look-Locker acquisition on a Bruker BioSpec 7.0 T MRI scanner. Six three-month-old Sprague-Dawley (SD) rats were also scanned as controls. All animals were euthanized after the three-month scans for histological and biochemical assessments of bile duct dilatation and hepatic fibrosis for comparison. PCK rats exhibited significantly increased liver T1 values (mean ± standard deviation = 935 ± 39 ms) compared with age-matched SD control rats (847 ± 26 ms, p = 0.01). One PCK rat exhibited severe cholangitis (mean T1 = 1413 ms), which occurs periodically in ARPKD patients. The observed increase in the in vivo liver T1 relaxation time correlated significantly with three histological and biochemical indicators of biliary dilatation and fibrosis: bile duct area percent (R = 0.85, p = 0.002), periportal fibrosis area percent (R = 0.82, p = 0.004), and hydroxyproline content (R = 0.76, p = 0.01). These results suggest that hepatic T1 relaxation time may provide a sensitive and non-invasive imaging biomarker to monitor ARPKD liver disease.
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Affiliation(s)
- Ying Gao
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Bernadette O. Erokwu
- Department of Radiology, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - David A. DeSantis
- Department of Nutrition, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Colleen M. Croniger
- Department of Nutrition, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Rebecca M. Schur
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Lan Lu
- Department of Radiology, Case Western Reserve University, Cleveland, Ohio, United States of America
- Department of Urology, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Jose Mariappuram
- CWRU Center for the Study of Kidney Disease and Biology, MetroHealth Campus, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Katherine M. Dell
- CWRU Center for the Study of Kidney Disease and Biology, MetroHealth Campus, Case Western Reserve University, Cleveland, Ohio, United States of America
- Cleveland Clinic Children’s, Cleveland, Ohio, United States of America
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Chris A. Flask
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, United States of America
- Department of Radiology, Case Western Reserve University, Cleveland, Ohio, United States of America
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, United States of America
- Corresponding author: Chris A. Flask, PhD, Associate Professor of Radiology, 11100 Euclid Ave / Bolwell B115, Cleveland, OH 44106, 216-844-4963,
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Greenway SC, Crossland DS, Hudson M, Martin SR, Myers RP, Prieur T, Hasan A, Kirk R. Fontan-associated liver disease: Implications for heart transplantation. J Heart Lung Transplant 2016; 35:26-33. [DOI: 10.1016/j.healun.2015.10.015] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 09/26/2015] [Accepted: 10/14/2015] [Indexed: 01/19/2023] Open
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Abstract
Many diseases cause substantial changes in the mechanical properties of tissue, and this provides motivation for developing methods to noninvasively assess the stiffness of tissue using imaging technology. Magnetic resonance elastography (MRE) has emerged as a versatile MRI-based technique, based on direct visualization of propagating shear waves in the tissues. The most established clinical application of MRE in the abdomen is in chronic liver disease. MRE is currently regarded as the most accurate noninvasive technique for detection and staging of liver fibrosis. Increasing experience and ongoing research is leading to exploration of applications in other abdominal organs. In this review article, the current use of MRE in liver disease and the potential future applications of this technology in other parts of the abdomen are surveyed.
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