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Belahnech Y, Martí Aguasca G, Dos Subirà L. Advances in Diagnostic and Interventional Catheterization in Adults with Fontan Circulation. J Clin Med 2024; 13:4633. [PMID: 39200775 PMCID: PMC11355634 DOI: 10.3390/jcm13164633] [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: 06/21/2024] [Revised: 07/19/2024] [Accepted: 08/05/2024] [Indexed: 09/02/2024] Open
Abstract
Over the past five decades, the Fontan procedure has been developed to improve the life expectancy of patients with congenital heart defects characterized by a functionally single ventricle. The Fontan circulation aims at redirecting systemic venous return to the pulmonary circulation in the absence of an impelling subpulmonary ventricle, which makes this physiology quite fragile and leads to several long-term complications. Despite the importance of hemodynamic assessment through cardiac catheterization in the management and follow-up of these patients, a thorough understanding of the ultimate functioning of this type of circulation is lacking, and the interpretation of the hemodynamic data is often complex. In recent years, new tools such as combined catheterization with cardiopulmonary exercise testing have been incorporated to improve the understanding of the hemodynamic profile of these patients. Furthermore, extensive percutaneous treatment options have been developed, addressing issues ranging from obstructive problems in Fontan pathway and acquired shunts through compensatory collaterals to the percutaneous treatment of lymphatic circulation disorders and transcatheter edge-to-edge repair of atrioventricular valves. The aim of this review is to detail the various tools used in cardiac catheterization for patients with Fontan circulation, analyze different percutaneous treatment strategies, and discuss the latest advancements in this field.
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Affiliation(s)
- Yassin Belahnech
- Adult Congenital Heart Disease Unit, Cardiology Department, Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (Y.B.); (G.M.A.)
| | - Gerard Martí Aguasca
- Adult Congenital Heart Disease Unit, Cardiology Department, Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (Y.B.); (G.M.A.)
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Laura Dos Subirà
- Adult Congenital Heart Disease Unit, Cardiology Department, Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (Y.B.); (G.M.A.)
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28029 Madrid, Spain
- European Reference Network for Rare, Low-Prevalence, or Complex Diseases of the Heart (ERN GUARD-Heart), Coordinating Center in Amsterdam, 1105 AZ Amsterdam, The Netherlands
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Festa P, Lovato L, Bianco F, Alaimo A, Angeli E, Baccano G, Barbi E, Bennati E, Bonhoeffer P, Bucciarelli V, Curione D, Ciliberti P, Clemente A, Di Salvo G, Esposito A, Ferroni F, Gaeta A, Giovagnoni A, Inserra MC, Leonardi B, Marcora S, Marrone C, Peritore G, Pergola V, Pluchinotta F, Puppini G, Stagnaro N, Raimondi F, Sandrini C, Spaziani G, Tchana B, Trocchio G, Ait-Ali L, Secinaro A. Recommendations for cardiovascular magnetic resonance and computed tomography in congenital heart disease: a consensus paper from the CMR/CCT Working Group of the Italian Society of Pediatric Cardiology and the Italian College of Cardiac Radiology endorsed by the Italian Society of Medical and Interventional Radiology (Part II). J Cardiovasc Med (Hagerstown) 2024; 25:473-487. [PMID: 38829936 DOI: 10.2459/jcm.0000000000001628] [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: 06/05/2024]
Abstract
Cardiovascular magnetic resonance (CMR) and computed tomography (CCT) are advanced imaging modalities that recently revolutionized the conventional diagnostic approach to congenital heart diseases (CHD), supporting echocardiography and often replacing cardiac catheterization. This is the second of two complementary documents, endorsed by experts from the Working Group of the Italian Society of Pediatric Cardiology and the Italian College of Cardiac Radiology of the Italian Society of Medical and Interventional Radiology, aimed at giving updated indications on the appropriate use of CMR and CCT in different clinical CHD settings, in both pediatrics and adults. In this article, support is also given to radiologists, pediatricians, cardiologists, and cardiac surgeons for indications and appropriateness criteria for CMR and CCT in the most referred CHD, following the proposed new criteria presented and discussed in the first document. This second document also examines the impact of devices and prostheses for CMR and CCT in CHD and additionally presents some indications for CMR and CCT exams when sedation or narcosis is needed.
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Affiliation(s)
- Pierluigi Festa
- Pediatric Cardiology and GUCH Unit, Fondazione 'G. Monasterio' CNR-Regione Toscana, Massa-Pisa
| | - Luigi Lovato
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Pediatric and Adult CardioThoracic and Vascular, Oncohematologic and Emergency Radiology Unit, Bologna
| | - Francesco Bianco
- Department of Paediatric and Congenital Cardiac Surgery and Cardiology, Azienda Ospedaliero-Universitaria Ospedali Riuniti Ancona 'Umberto I, G. M. Lancisi, G. Salesi', Ancona
- Congenital Heart Diseases Working Group of the Italian Society of Cardiology, Rome
| | - Annalisa Alaimo
- Congenital Heart Diseases Working Group of the Italian Society of Cardiology, Rome
- U.O.C. di Cardiologia Pediatrica, ARNAS Civico-Di Cristina-Benfratelli, Palermo
| | - Emanuela Angeli
- Pediatric & Grown-up Congenital Cardiac Surgery Unit, Cardiothoracic-Vascular Department, University Hospital S. Orsola-Malpighi, Bologna
| | - Giovanna Baccano
- Department of Pediatric Cardiology - Centro Cardiologico Pediatrico Mediterraneo, Taormina
| | - Egidio Barbi
- Institute for Maternal and Child Health, IRCCS 'Burlo Garofolo'
- Department of Pediatrics, University of Trieste, Trieste
| | - Elena Bennati
- Congenital Heart Diseases Working Group of the Italian Society of Cardiology, Rome
- Department of Pediatric Cardiology, IRCCS Meyer Children's Hospital, Florence
| | | | - Valentina Bucciarelli
- Department of Paediatric and Congenital Cardiac Surgery and Cardiology, Azienda Ospedaliero-Universitaria Ospedali Riuniti Ancona 'Umberto I, G. M. Lancisi, G. Salesi', Ancona
- Congenital Heart Diseases Working Group of the Italian Society of Cardiology, Rome
| | - Davide Curione
- Advanced Cardiovascular Imaging Unit - Department of Imaging, Bambino Gesù Children's Hospital
| | - Paolo Ciliberti
- Congenital Heart Diseases Working Group of the Italian Society of Cardiology, Rome
- Cardiology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome
| | - Alberto Clemente
- UOC Imaging Multimodale Cardiovascolare e Neuroradiologico - Dipartimento Immagini, Fondazione Toscana 'Gabriele Monasterio'/CNR - Pisa
| | - Giovanni Di Salvo
- Congenital Heart Diseases Working Group of the Italian Society of Cardiology, Rome
- Department of Women's and Children's Health, University of Padua, Padua
| | - Antonio Esposito
- Clinical and Experimental Radiology Unit, Experimental Imaging Center IRCCS Ospedale San Raffaele, Milan
| | | | - Alberto Gaeta
- Radiology Unit, Pediatric Hospital Giovanni XXIII, Bari
| | - Andrea Giovagnoni
- Radiology department, Azienda Ospedaliero-Universitaria Ospedali Riuniti Ancona 'Umberto I, G. M. Lancisi, G. Salesi', Ancona
| | - Maria Cristina Inserra
- Congenital Heart Diseases Working Group of the Italian Society of Cardiology, Rome
- Radiologia 2 - Centro Alta Specialità e Trapianti (C.A.S.T.), Azienda Ospedaliero Universitaria Policlinico San Marco. Catania
| | - Benedetta Leonardi
- Congenital Heart Diseases Working Group of the Italian Society of Cardiology, Rome
- Cardiology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome
| | - Simona Marcora
- Congenital Heart Diseases Working Group of the Italian Society of Cardiology, Rome
- USSD Cardiologia Pediatrica, ASST Grande Ospedale Metropolitano Niguarda, Milan
| | - Chiara Marrone
- Pediatric Cardiology and GUCH Unit, Fondazione 'G. Monasterio' CNR-Regione Toscana, Massa-Pisa
| | - Giuseppe Peritore
- U.O.C. di Radiodiagnostica, ARNAS Civico-Di Cristina-Benfratelli, Palermo
| | - Valeria Pergola
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua
| | - Francesca Pluchinotta
- Department of Pediatric Cardiology and Adult Congenital Heart Disease, IRCCS Policlinico San Donato, Milan
| | | | | | - Francesca Raimondi
- Department of Pediatric Cardiology, IRCCS Meyer Children's Hospital, Florence
| | - Camilla Sandrini
- Division of Cardiology, Department of Medicine, University of Verona, Verona
| | - Gaia Spaziani
- Department of Pediatric Cardiology, IRCCS Meyer Children's Hospital, Florence
| | - Bertrand Tchana
- Department of Pediatrics, Ospedale dei Bambini Barilla, University of Parma, Parma
| | | | - Lamia Ait-Ali
- Institute of Clinical Physiology, National Research Institute, Pisa, Italy
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Rifé-Pardo È, Rello P, Sambola A, Gordon B. Successful thromboaspiration of bilateral pulmonary thromboembolism in a Fontan circulation patient: a case report. Eur Heart J Case Rep 2024; 8:ytae190. [PMID: 38915741 PMCID: PMC11195311 DOI: 10.1093/ehjcr/ytae190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 04/03/2024] [Accepted: 04/12/2024] [Indexed: 06/26/2024]
Abstract
Background Fontan surgery aims to palliate univentricular congenital heart diseases in which biventricular repair is not feasible. A large spectrum of early and late complications has been described in literature. However, pulmonary thromboembolism represents a rare complication in these patients, leading to a scarcity of evidence regarding diagnosis and treatment strategies. Case summary We present a case of a 27-year-old woman born with a complex cyanotic congenital heart disease, namely pulmonary and tricuspid stenosis with subaortic interventricular communication and atrial septal defect, who underwent palliation surgery with Blalock-Taussig shunt, bidirectional Glenn, and extracardiac Fontan. She developed acute respiratory failure and was admitted to the hospital, being diagnosed with bilateral thromboembolism. Since she was haemodynamically stable, initially, a conservative approach was chosen. However, due to no clinical improvement, she subsequently underwent bilateral thromboaspiration with restoration of pulmonary circulation. Discussion Due to the unique Fontan pathophysiology, the possible physiological and clinical implications of pulmonary thromboembolism in this condition are profound. Thus, care and imaging tests in specialized centres are important as the management of these patients is different from those with biventricular physiology.
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Affiliation(s)
- Èlia Rifé-Pardo
- Department of Cardiology, Research Institute Vall d’Hebron University Hospital, CIBER-CV, Passeig Vall d'Hebrón 119-129, 08035 Barcelona, Spain
| | - Pau Rello
- Department of Cardiology, Research Institute Vall d’Hebron University Hospital, CIBER-CV, Passeig Vall d'Hebrón 119-129, 08035 Barcelona, Spain
| | - Antonia Sambola
- Department of Cardiology, Research Institute Vall d’Hebron University Hospital, CIBER-CV, Passeig Vall d'Hebrón 119-129, 08035 Barcelona, Spain
| | - Blanca Gordon
- Department of Cardiology, Research Institute Vall d’Hebron University Hospital, CIBER-CV, Passeig Vall d'Hebrón 119-129, 08035 Barcelona, Spain
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Krishnamurthy R, Suman G, Chan SS, Kirsch J, Iyer RS, Bolen MA, Brown RKJ, El-Sherief AH, Galizia MS, Hanneman K, Hsu JY, de Rosen VL, Rajiah PS, Renapurkar RD, Russell RR, Samyn M, Shen J, Villines TC, Wall JJ, Rigsby CK, Abbara S. ACR Appropriateness Criteria® Congenital or Acquired Heart Disease. J Am Coll Radiol 2023; 20:S351-S381. [PMID: 38040460 DOI: 10.1016/j.jacr.2023.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/22/2023] [Indexed: 12/03/2023]
Abstract
Pediatric heart disease is a large and diverse field with an overall prevalence estimated at 6 to 13 per 1,000 live births. This document discusses appropriateness of advanced imaging for a broad range of variants. Diseases covered include tetralogy of Fallot, transposition of great arteries, congenital or acquired pediatric coronary artery abnormality, single ventricle, aortopathy, anomalous pulmonary venous return, aortopathy and aortic coarctation, with indications for advanced imaging spanning the entire natural history of the disease in children and adults, including initial diagnosis, treatment planning, treatment monitoring, and early detection of complications. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Garima Suman
- Research Author, Mayo Clinic, Rochester, Minnesota
| | | | - Jacobo Kirsch
- Panel Chair, Cleveland Clinic Florida, Weston, Florida
| | - Ramesh S Iyer
- Panel Chair, Seattle Children's Hospital, Seattle, Washington
| | | | - Richard K J Brown
- University of Utah, Department of Radiology and Imaging Sciences, Salt Lake City, Utah; Commission on Nuclear Medicine and Molecular Imaging
| | | | | | - Kate Hanneman
- Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Joe Y Hsu
- Kaiser Permanente, Los Angeles, California
| | | | | | | | - Raymond R Russell
- The Warren Alpert School of Medicine at Brown University, Providence, Rhode Island; American Society of Nuclear Cardiology
| | - Margaret Samyn
- Children's Hospital of Wisconsin, Milwaukee, Wisconsin; Society for Cardiovascular Magnetic Resonance
| | - Jody Shen
- Stanford University, Stanford, California
| | - Todd C Villines
- University of Virginia Health System, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography
| | - Jessica J Wall
- University of Washington, Seattle, Washington; American College of Emergency Physicians
| | - Cynthia K Rigsby
- Specialty Chair, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Suhny Abbara
- Specialty Chair, University of Texas Southwestern Medical Center, Dallas, Texas
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Medina Perez M, Lichtenberger JP, Huppmann AR, Gomez M, Ramirez Suarez KI, Foran A, Vaiyani D, White AM, Biko DM. Cardiac and Pericardial Neoplasms in Children: Radiologic-Pathologic Correlation. Radiographics 2023; 43:e230010. [PMID: 37561644 DOI: 10.1148/rg.230010] [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: 08/12/2023]
Abstract
Primary cardiac and pericardial neoplasms are rare in the pediatric population and can include both benign and malignant lesions. Rhabdomyomas, teratomas, fibromas, and hemangiomas are the most common benign tumors. The most common primary cardiac malignancies are soft-tissue sarcomas, including undifferentiated sarcomas, rhabdomyosarcomas, and fibrosarcomas. However, metastatic lesions are more common than primary cardiac neoplasms. Children with primary cardiac and pericardial tumors may present with nonspecific cardiovascular symptoms, and their clinical presentation may mimic that of more common nonneoplastic cardiac disease. The diagnosis of cardiac tumors has recently been facilitated using noninvasive cardiac imaging. Echocardiography is generally the first-line modality for evaluation. Cardiac MRI and CT are used for tissue characterization and evaluation of tumor size, extension, and physiologic effect. The varied imaging appearances of primary cardiac neoplasms can be explained by their underlying abnormality. Treatment of these lesions varies from conservative management, with spontaneous regression of some lesions such as rhabdomyomas, to surgical resection, particularly in patients with associated heart failure. With adequate imaging techniques and knowledge of the pathologic basis of the neoplasm, it is often possible to differentiate benign from malignant tumors, which can greatly affect adequate and timely treatment. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.
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Affiliation(s)
- Mariangeles Medina Perez
- From the Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104 (M.M.P.); Sections of Thoracic Radiology (J.P.L.) and Pediatric Radiology (D.M.B.), American College of Radiology Institute of Radiologic Pathology, Silver Spring, Md; Department of Radiology, George Washington University, Washington, DC (J.P.L.); Department of Pathology, University of South Carolina School of Medicine, Greenville, SC (A.R.H.); Department of Pathology, MD Anderson Cancer Center, Houston, Tex (M.G.); and Department of Radiology (K.I.R.S., A.F., A.M.W., D.M.B.) and Division of Cardiology (D.V.), Children's Hospital of Philadelphia, Philadelphia, Penn
| | - John P Lichtenberger
- From the Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104 (M.M.P.); Sections of Thoracic Radiology (J.P.L.) and Pediatric Radiology (D.M.B.), American College of Radiology Institute of Radiologic Pathology, Silver Spring, Md; Department of Radiology, George Washington University, Washington, DC (J.P.L.); Department of Pathology, University of South Carolina School of Medicine, Greenville, SC (A.R.H.); Department of Pathology, MD Anderson Cancer Center, Houston, Tex (M.G.); and Department of Radiology (K.I.R.S., A.F., A.M.W., D.M.B.) and Division of Cardiology (D.V.), Children's Hospital of Philadelphia, Philadelphia, Penn
| | - Alison R Huppmann
- From the Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104 (M.M.P.); Sections of Thoracic Radiology (J.P.L.) and Pediatric Radiology (D.M.B.), American College of Radiology Institute of Radiologic Pathology, Silver Spring, Md; Department of Radiology, George Washington University, Washington, DC (J.P.L.); Department of Pathology, University of South Carolina School of Medicine, Greenville, SC (A.R.H.); Department of Pathology, MD Anderson Cancer Center, Houston, Tex (M.G.); and Department of Radiology (K.I.R.S., A.F., A.M.W., D.M.B.) and Division of Cardiology (D.V.), Children's Hospital of Philadelphia, Philadelphia, Penn
| | - Mariangela Gomez
- From the Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104 (M.M.P.); Sections of Thoracic Radiology (J.P.L.) and Pediatric Radiology (D.M.B.), American College of Radiology Institute of Radiologic Pathology, Silver Spring, Md; Department of Radiology, George Washington University, Washington, DC (J.P.L.); Department of Pathology, University of South Carolina School of Medicine, Greenville, SC (A.R.H.); Department of Pathology, MD Anderson Cancer Center, Houston, Tex (M.G.); and Department of Radiology (K.I.R.S., A.F., A.M.W., D.M.B.) and Division of Cardiology (D.V.), Children's Hospital of Philadelphia, Philadelphia, Penn
| | - Karen I Ramirez Suarez
- From the Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104 (M.M.P.); Sections of Thoracic Radiology (J.P.L.) and Pediatric Radiology (D.M.B.), American College of Radiology Institute of Radiologic Pathology, Silver Spring, Md; Department of Radiology, George Washington University, Washington, DC (J.P.L.); Department of Pathology, University of South Carolina School of Medicine, Greenville, SC (A.R.H.); Department of Pathology, MD Anderson Cancer Center, Houston, Tex (M.G.); and Department of Radiology (K.I.R.S., A.F., A.M.W., D.M.B.) and Division of Cardiology (D.V.), Children's Hospital of Philadelphia, Philadelphia, Penn
| | - Ann Foran
- From the Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104 (M.M.P.); Sections of Thoracic Radiology (J.P.L.) and Pediatric Radiology (D.M.B.), American College of Radiology Institute of Radiologic Pathology, Silver Spring, Md; Department of Radiology, George Washington University, Washington, DC (J.P.L.); Department of Pathology, University of South Carolina School of Medicine, Greenville, SC (A.R.H.); Department of Pathology, MD Anderson Cancer Center, Houston, Tex (M.G.); and Department of Radiology (K.I.R.S., A.F., A.M.W., D.M.B.) and Division of Cardiology (D.V.), Children's Hospital of Philadelphia, Philadelphia, Penn
| | - Danish Vaiyani
- From the Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104 (M.M.P.); Sections of Thoracic Radiology (J.P.L.) and Pediatric Radiology (D.M.B.), American College of Radiology Institute of Radiologic Pathology, Silver Spring, Md; Department of Radiology, George Washington University, Washington, DC (J.P.L.); Department of Pathology, University of South Carolina School of Medicine, Greenville, SC (A.R.H.); Department of Pathology, MD Anderson Cancer Center, Houston, Tex (M.G.); and Department of Radiology (K.I.R.S., A.F., A.M.W., D.M.B.) and Division of Cardiology (D.V.), Children's Hospital of Philadelphia, Philadelphia, Penn
| | - Ammie M White
- From the Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104 (M.M.P.); Sections of Thoracic Radiology (J.P.L.) and Pediatric Radiology (D.M.B.), American College of Radiology Institute of Radiologic Pathology, Silver Spring, Md; Department of Radiology, George Washington University, Washington, DC (J.P.L.); Department of Pathology, University of South Carolina School of Medicine, Greenville, SC (A.R.H.); Department of Pathology, MD Anderson Cancer Center, Houston, Tex (M.G.); and Department of Radiology (K.I.R.S., A.F., A.M.W., D.M.B.) and Division of Cardiology (D.V.), Children's Hospital of Philadelphia, Philadelphia, Penn
| | - David M Biko
- From the Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104 (M.M.P.); Sections of Thoracic Radiology (J.P.L.) and Pediatric Radiology (D.M.B.), American College of Radiology Institute of Radiologic Pathology, Silver Spring, Md; Department of Radiology, George Washington University, Washington, DC (J.P.L.); Department of Pathology, University of South Carolina School of Medicine, Greenville, SC (A.R.H.); Department of Pathology, MD Anderson Cancer Center, Houston, Tex (M.G.); and Department of Radiology (K.I.R.S., A.F., A.M.W., D.M.B.) and Division of Cardiology (D.V.), Children's Hospital of Philadelphia, Philadelphia, Penn
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Teng C, Shrestha R, Phillips J. Challenges in diagnosing pulmonary embolism in an adult with Fontan physiology: a case report. Eur Heart J Case Rep 2023; 7:ytad330. [PMID: 37554959 PMCID: PMC10405353 DOI: 10.1093/ehjcr/ytad330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 06/26/2023] [Accepted: 07/19/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND With the increasing longevity of congenital heart disease patients and limited number of adult congenital heart disease specialists, it is becoming increasingly imperative for general cardiologists to understand not only the unique physiology of Fontan patients but also imaging protocol considerations when treating this group of patients. CASE SUMMARY Here, we present a patient with a history of congenital tricuspid atresia status after the Fontan procedure who presented for gut translocation-related bacteraemia. Importantly, the patient was falsely diagnosed with pulmonary embolism resulting from inaccurate acquisition of computed tomography imaging. DISCUSSION This case illustrates the complex intricacies that clinicians should consider when facing the challenge of treating Fontan patients.
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Affiliation(s)
- Catherine Teng
- Division of Cardiology, Department of Medicine, University of Texas Health Science Center San Antonio, TX, USA
| | - Ribesh Shrestha
- Division of Cardiology, Department of Medicine, University of Texas Health Science Center San Antonio, TX, USA
- Department of Internal Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Jason Phillips
- Division of Cardiology, Department of Medicine, University of Texas Health Science Center San Antonio, TX, USA
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Moscatelli S, Borrelli N, Sabatino J, Leo I, Avesani M, Montanaro C, Di Salvo G. Role of Cardiovascular Imaging in the Follow-Up of Patients with Fontan Circulation. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121875. [PMID: 36553321 PMCID: PMC9777137 DOI: 10.3390/children9121875] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 11/27/2022] [Accepted: 11/28/2022] [Indexed: 12/02/2022]
Abstract
Since its first description in 1971, the Fontan procedure and its modifications have led to a substantial improvement in the survival rates of patients with a variety of types of complex Congenital Heart Disease (CHD) characterised by the presence of a single, dominant ventricle. However, despite the significant improvement of the prognosis over the years, Fontan patients are still exposed to several cardiovascular and systemic complications. It is, therefore, important to fully understand the pitfalls hidden behind a Fontan anatomy and the potential predictors of ventricular failure. Cardiovascular imaging plays a key role in this context, allowing for the early identification of complications with important prognostic implications. Echocardiography remains the first-line imaging modality for serial evaluation of Fontan patients. However, there is a growing role of cardiovascular magnetic resonance and cardiac computed tomography from pre-operative assessment to longitudinal follow-up. The aim of this paper will be to provide a comprehensive overview of the role, strengths, and weaknesses of each imaging modality in the assessment of congenital cardiac conditions palliated with the Fontan procedure.
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Affiliation(s)
- Sara Moscatelli
- Paediatric Cardiology Department, Royal Brompton Hospital Harefield NHS Foundation Trust, London SW3 5NP, UK
| | - Nunzia Borrelli
- Adult Congenital Heart Disease Unit, A.O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Jolanda Sabatino
- Division of Paediatric Cardiology, Department of Women and Children’s Health, University Hospital Padua, 35128 Padua, Italy
- Paediatric Research Institute (IRP), Città Della Speranza, 35127 Padua, Italy
| | - Isabella Leo
- Department of Medical and Surgical Sciences, Magna Grecia University, 88100 Catanzaro, Italy
- Cardiac Magnetic Resonance Department, Royal Brompton Hospital Harefield NHS Foundation Trust, London SW3 5NP, UK
| | - Martina Avesani
- Division of Paediatric Cardiology, Department of Women and Children’s Health, University Hospital Padua, 35128 Padua, Italy
| | - Claudia Montanaro
- Adult Congenital Department, Royal Brompton Hospital & Harefield NHS Foundation Trust, London SW3 5NP, UK
| | - Giovanni Di Salvo
- Division of Paediatric Cardiology, Department of Women and Children’s Health, University Hospital Padua, 35128 Padua, Italy
- Paediatric Research Institute (IRP), Città Della Speranza, 35127 Padua, Italy
- Correspondence:
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Tan S, Hamarati LB, Rajiah PS, Le Gal G, Ko JP, Stojanovska J. CTA of Acute Pulmonary Embolism: Best Practices. Semin Roentgenol 2022; 57:313-323. [DOI: 10.1053/j.ro.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/15/2022] [Accepted: 08/19/2022] [Indexed: 11/11/2022]
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Goo HW. Contrast-Enhanced CT Protocol for the Fontan Pathway: Comparison Between 1- and 3-Minute Scan Delays. Pediatr Cardiol 2022; 43:1104-1113. [PMID: 35107628 DOI: 10.1007/s00246-022-02830-2] [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: 12/29/2021] [Accepted: 01/18/2022] [Indexed: 10/19/2022]
Abstract
Optimal enhancement of the Fontan pathway is crucial for the accurate CT evaluation. Current guidelines for contrast-enhanced CT protocols are rather inconsistent in scan delays and injection methods. This single-center, retrospective study was performed to compare objective measures of contrast enhancement between 1- and 3-min scan delays (41 and 36 patients, respectively) to determine a better contrast-enhanced CT protocols for evaluating the Fontan pathway. In both groups, a biphasic injection protocol, in which 50% diluted contrast agent (the amount of iodinated contrast agent: 2.0 mL/kg; the amount of saline: 2.0 mL/kg) was injected at the injection rate of 0.5‒2.5 mL/s for 50 s followed by a saline flush at the same injection rate (0.5‒2.5 mL/s), was used. The degree and heterogeneity of cardiovascular enhancement, image noise, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) were quantitatively evaluated. The mean densities of all cardiovascular structures were significantly higher in the 1-min delay protocol than in the 3-min delay protocols (p < 0.001). Heterogeneous enhancement (normalized standard deviation > 0.70) in the Fontan pathway was significantly more frequent in the 1-min delay protocol (p < 0.001). No significant differences were found in image noise (p > 0.141) and the frequency showing suboptimal noise (p = 1.000) between the two protocols. SNR and CNR were significantly lower in the 3-min delay protocol (p < 0.001). Compared with the 1-min delay protocol, the 3-min delay protocol achieved more homogeneous enhancement in the Fontan pathway on CT but showed lower contrast enhancement, SNR, and, CNR, indicating the need for further improvement.
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Affiliation(s)
- Hyun Woo Goo
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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Kumar P, Bhatia M. Role of CT in the Pre- and Postoperative Assessment of Conotruncal Anomalies. Radiol Cardiothorac Imaging 2022; 4:e210089. [PMID: 35923747 PMCID: PMC9308465 DOI: 10.1148/ryct.210089] [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: 03/27/2021] [Revised: 04/25/2022] [Accepted: 05/19/2022] [Indexed: 06/15/2023]
Abstract
Conotruncal anomalies, also referred to as outflow tract anomalies, are congenital heart defects that result from abnormal septation of the great vessels' outflow tracts. The major conotruncal anomalies include tetralogy of Fallot, double-outlet right ventricle, transposition of the great arteries, truncus arteriosus, and interrupted aortic arch. Other defects, which are often components of the major anomalies, include pulmonary atresia with ventricular septal defect, pulmonary valve agenesis, aortopulmonary window, and double-outlet left ventricle. CT has emerged as a robust diagnostic tool in preoperative and postoperative assessment of various congenital heart diseases, including conotruncal anomalies. The data provided with multidetector CT imaging are useful for treatment planning and follow-up monitoring after surgery or intervention. Unlike echocardiography and MRI, CT is not limited by a small acoustic window, metallic devices, and need for sedation or anesthesia. Major advances in CT equipment, including dual-source scanners, wide-detector scanners, high-efficiency detectors, higher x-ray tube power, automatic tube current modulation, and advanced three-dimensional postprocessing, provide a low-risk, high-quality alternative to diagnostic cardiac catheterization and MRI. This review explores the various conotruncal anomalies and elucidates the role of CT imaging in their pre- and postoperative assessment. Keywords: CT, CT Angiography, Stents, Pediatrics © RSNA, 2022.
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Affiliation(s)
- Parveen Kumar
- Department of Radiodiagnosis and Imaging, Fortis Escort Heart Institute, Okhla Road, New Delhi 110025, India
| | - Mona Bhatia
- Department of Radiodiagnosis and Imaging, Fortis Escort Heart Institute, Okhla Road, New Delhi 110025, India
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Determination of Contrast Timing by Time-Resolved Magnetic Resonance Angiography in Patients With Bidirectional Glenn and Hemi-Fontan Anastomoses. J Comput Assist Tomogr 2022; 46:742-746. [PMID: 35617648 DOI: 10.1097/rct.0000000000001332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Children with single-ventricle congenital heart disease undergo a series of operations to maintain their pulmonary circulation including bidirectional Glenn (BDG) or hemi-Fontan in the second stage to create a superior cavopulmonary anastomosis. We aimed to optimize cardiovascular angiography protocols by determining optimal contrast timing of pulmonary and systemic circulation on magnetic resonance angiography (MRA) performed with the technique of time-resolved imaging with interleaved stochastic trajectories (TWIST). METHODS AND MATERIALS Cardiac TWIST MRA with lower extremity (LE) contrast injection was analyzed in 92 consecutive patients with a BDG or hemi-Fontan anastomosis. Contrast arrival time to inferior vena cava was set to zero to determine the relative time-to-peak (TTP) of the target vessels. Time-to-peak of each vessel was compared by age (<2 or ≥2 y), ejection fraction (<54% or ≥54%), the median values of heart rate (<111 or ≥111 beats per minute), body surface area (BSA, <0.59 or ≥0.59), cardiac index (<6.04 or ≥6.04), and indexed ascending aorta flow (AscAo_i, <5.3 or ≥5.3). The TTP of the vessels was also correlated with the volumetric parameters. RESULTS The mean age of 92 patients (32 female, 60 male) was 3.1 years (0.7-5.6 years). With LE injection, the first peak was depicted in AscAo. Time-to-peak of the pulmonary arteries was approximately 9 seconds later than AscAo. The TTP difference between pulmonary arteries and AscAo was shorter in high heart rate group (8.3 vs 10 seconds, P < 0.001). The TTP difference between AscAo and the mean of pulmonary arteries was significantly shorter in high cardiac index group (8.4 vs 9.9 seconds, P < 0.01) and high AscAo_i group (8.7 vs 9.7 seconds, P = 0.03). The TTP differences were not significant by age, ejection fraction, and BSA. Cardiac index and AscAo_i were negatively correlated with all TTPs except AscAo. The ejection fraction, stroke volume, and atrioventricular regurgitation fraction did not correlate with the TTP. CONCLUSIONS In patients with BDG or hemi-Fontan anastomosis, TTP of the pulmonary arteries on TWIST MRA via LE intravenous injection is approximately 9 seconds later than AscAo, approximately 8 and 10 seconds later in high and low heart rate groups, respectively. Cardiac index and AscAo_i have less effect on the TTP than the heart rate. There was no TTP difference of the pulmonary arteries by age, BSA, and ejection fraction and no correlation with ejection fraction, stroke volume, and atrioventricular regurgitation fraction. These data can be used to guide timing of pulmonary arterial enhancement of single-ventricle patients after BDG or hemi-Fontan anastomosis.
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Cardiovascular Computed Tomography in Pediatric Congenital Heart Disease: A State of the Art Review. J Cardiovasc Comput Tomogr 2022; 16:467-482. [DOI: 10.1016/j.jcct.2022.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 01/04/2023]
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Ciliberti P, Ciancarella P, Bruno P, Curione D, Bordonaro V, Lisignoli V, Panebianco M, Chinali M, Secinaro A, Galletti L, Guccione P. Cardiac Imaging in Patients After Fontan Palliation: Which Test and When? Front Pediatr 2022; 10:876742. [PMID: 35652057 PMCID: PMC9149285 DOI: 10.3389/fped.2022.876742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/13/2022] [Indexed: 11/13/2022] Open
Abstract
The Fontan operation represents the final stage of a series of palliative surgical procedures for children born with complex congenital heart disease, where a "usual" biventricular physiology cannot be restored. The palliation results in the direct connection of the systemic venous returns to the pulmonary arterial circulation without an interposed ventricle. In this unique physiology, systemic venous hypertension and intrathoracic pressures changes due to respiratory mechanics play the main role for propelling blood through the pulmonary vasculature. Although the Fontan operation has dramatically improved survival in patients with a single ventricle congenital heart disease, significant morbidity is still a concern. Patients with Fontan physiology are in fact suffering from a multitude of complications mainly due to the increased systemic venous pressure. Consequently, these patients need close clinical and imaging monitoring, where cardiac exams play a key role. In this article, we review the main cardiac imaging modalities available, summarizing their main strengths and limitations in this peculiar setting. The main purpose is to provide a practical approach for all clinicians involved in the care of these patients, even for those less experienced in cardiac imaging.
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Affiliation(s)
- Paolo Ciliberti
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Paolo Ciancarella
- Advanced Cardiothoracic Imaging Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Pasqualina Bruno
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Davide Curione
- Advanced Cardiothoracic Imaging Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Veronica Bordonaro
- Advanced Cardiothoracic Imaging Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Veronica Lisignoli
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Mario Panebianco
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Marcello Chinali
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Aurelio Secinaro
- Advanced Cardiothoracic Imaging Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Lorenzo Galletti
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Paolo Guccione
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
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OUP accepted manuscript. Eur Heart J Cardiovasc Imaging 2022; 23:e279-e289. [DOI: 10.1093/ehjci/jeac048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 03/02/2022] [Indexed: 11/14/2022] Open
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15
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Management of patients with single ventricle physiology across the lifespan: contributions from magnetic resonance and computed tomography imaging. Can J Cardiol 2022; 38:946-962. [DOI: 10.1016/j.cjca.2022.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/27/2021] [Accepted: 01/02/2022] [Indexed: 12/12/2022] Open
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16
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Gamal El-Deen MA, Ibrahim AS, Abdeldayem EH, Elia RZ, Romeih S. Assessment of superior cavo-pulmonary anastomoses (Glenn shunt) by cardiac magnetic resonance imaging in comparison with multi-slice computed tomography. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2021. [DOI: 10.1186/s43055-021-00676-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Multi-slice computed tomography (MSCT) angiography is the gold standard imaging modality to evaluate the patency of Glenn shunt and the presence of veno–veno collaterals. The goal of this study is to evaluate the ability of two cardiac magnetic resonance imaging (MRI) techniques to assess the patency of Glenn shunt and the presence of veno–veno collaterals compared to MSCT angiography.
Results
Patients with Glenn shunt had MSCT angiography and cardiac MRI using two techniques: TWIST (Time-resolved angiography With Stochastic Trajectories) and the three-dimensional (3D) post-contrast whole heart techniques. MSCT angiography and cardiac MRI images were post-processed for quantitative and qualitative assessment of Glenn shunt and veno–veno collaterals. Our study included 29 patients (17 male, 59%) with Glenn shunt, the median age was 22 years (range 3–36 years). 3D post-contrast whole heart images give similar results compared to MSCT angiography results in the evaluation of Glenn shunt and veno–veno collaterals, 100% agreement in Glenn shunt visualization and agreement was 86.2% in the detection of veno–veno collaterals with a perfect agreement (kappa = 1) as regards their proximal connection to superior vena cava (SVC). While TWIST showed lower agreement compared to MSCT angiography results, 87.5% agreement in Glenn shunt visualization and agreement was 68.9% in the detection of veno–veno collaterals with poor agreement (kappa = 0.266) as regards their proximal connection to SVC.
Conclusions
3D post-contrast whole heart MRI images have similar results as MSCT angiography in the evaluation of superior cavo-pulmonary anastomosis and can be a good and safer alternative to MSCT angiography.
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John S, Schoeneberg L, Greenleaf CE, Salazar JD, Adebo DA. Pre- and post-operative cardiovascular CT in Stage I single ventricle palliation. J Card Surg 2021; 37:322-328. [PMID: 34845746 DOI: 10.1111/jocs.16162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 11/18/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The aim of this study is to describe clinical utility of low dose cardiac computed tomography (CT) in the evaluation of single ventricle physiology before and after Stage I palliation. BACKGROUND Despite the increased utilization of CT imaging and advancement of CT technology, there are limited studies describing the routine clinical use of cardiac CT and radiation dose parameters in the single ventricle Stage I palliation. METHODS This single center, retrospective study included 57 infants with single ventricle physiology who underwent cardiac CT scans between January 1, 2016 and November 30, 2020. Patients' demographic information, diagnosis, indication, total dose length product (DLP), computed tomographic dose index volume (CTDIvol), cardiac CT findings and intraoperative or intraprocedural findings were reviewed. Estimated effective radiation dose was calculated using a previously published conversion rate. RESULTS The studies were performed using different generations of CT scanners over the 4 years period: Somatom AS 128, Somatom definition edge, Somatom Force (Siemens Medical Solutions). The studies performed with dual source scanner with prospective gated technique have lower radiation dose exposure with median effective radiation dose of 0.32 mSv. CONCLUSION Pre- and post-operative cardiovascular CT in Stage I single ventricle palliation using newer generation scanners with prospective gated technique can be done with minimal radiation exposure and good image quality. Cardiac CT is a powerful imaging modality for better management planning in this group of patients.
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Affiliation(s)
- Sheba John
- Division of Pediatric Cardiology, Children's Heart Institute, University of Texas Medical School at Houston, Houston, Texas, USA
| | - Laura Schoeneberg
- Division of Pediatric Cardiology, Children's Heart Institute, University of Texas Medical School at Houston, Houston, Texas, USA
| | - Christopher E Greenleaf
- Division of Cardiothoracic Surgery, Children's Heart Institute, Memorial Hermann Hospital, University of Texas Health McGovern Medical School, Houston, Texas, USA
| | - Jorge D Salazar
- Division of Cardiothoracic Surgery, Children's Heart Institute, Memorial Hermann Hospital, University of Texas Health McGovern Medical School, Houston, Texas, USA
| | - Dilachew A Adebo
- Division of Pediatric Cardiology, Children's Heart Institute, University of Texas Medical School at Houston, Houston, Texas, USA
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Pushparajah K. Non-invasive Imaging in the Evaluation of Cardiac Shunts for Interventional Closure. Front Cardiovasc Med 2021; 8:651726. [PMID: 34222361 PMCID: PMC8253251 DOI: 10.3389/fcvm.2021.651726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/08/2021] [Indexed: 11/13/2022] Open
Abstract
Multimodality imaging provides important information to guide patient selection and pre-procedural decision making for shunt lesions in CHD. While echocardiography, CT, and CMR are well-established, 3D printing and now virtual reality imaging are beginning to show promise.
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Affiliation(s)
- Kuberan Pushparajah
- School of Biomedical Engineering and Imaging Sciences, King's College London, St Thomas' Hospital, London, United Kingdom.,Department of Paediatric Cardiology, Evelina London Children's Hospital, London, United Kingdom
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Nguyen ET, Hague C, Manos D, Memauri B, Souza C, Taylor J, Dennie C. Canadian Society of Thoracic Radiology/Canadian Association of Radiologists Best Practice Guidance for Investigation of Acute Pulmonary Embolism, Part 2: Technical Issues and Interpretation Pitfalls. Can Assoc Radiol J 2021; 73:214-227. [PMID: 33781102 DOI: 10.1177/08465371211000739] [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] [Indexed: 11/15/2022] Open
Abstract
The investigation of acute pulmonary embolism is a common task for radiologists in Canada. Technical image quality and reporting quality must be excellent; pulmonary embolism is a life-threatening disease that should not be missed but overdiagnosis and unnecessary treatment should be avoided. The most frequently performed imaging investigation, computed tomography pulmonary angiogram (CTPA), can be limited by poor pulmonary arterial opacification, technical artifacts and interpretative errors. Image quality can be affected by patient factors (such as body habitus, motion artifact and cardiac output), intravenous (IV) contrast protocols (including the timing, rate and volume of IV contrast administration) and common physics artifacts (including beam hardening). Mimics of acute pulmonary embolism can be seen in normal anatomic structures, disease in non-vascular structures and pulmonary artery filling defects not related to acute pulmonary emboli. Understanding these pitfalls can help mitigate error, improve diagnostic quality and optimize patient outcomes. Dual energy computed tomography holds promise to improve imaging diagnosis, particularly in clinical scenarios where routine CTPA may be problematic, including patients with impaired renal function and patients with altered cardiac anatomy.
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Affiliation(s)
- Elsie T Nguyen
- Joint Department of Medical Imaging, 33540Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Cameron Hague
- Department of Radiology, 12358University of British Columbia, Vancouver, Canada
| | - Daria Manos
- Department of Diagnostic Radiology, 3688Dalhousie University, Halifax, Nova Scotia, Canada
| | - Brett Memauri
- Cardiothoracic Sciences Division, St. Boniface General Hospital, 12359University of Manitoba, Winnipeg, Manitoba, Canada
| | - Carolina Souza
- Department of Medical Imaging, 10055The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Jana Taylor
- 54473McGill University Health Centre, Montreal, Quebec, Canada
| | - Carole Dennie
- Department of Medical Imaging, 10055The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
- 27337Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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20
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Kumar P, Bhatia M. Computed Tomography in the Evaluation of Fontan Circulation. J Cardiovasc Imaging 2021; 29:108-122. [PMID: 33605094 PMCID: PMC8099570 DOI: 10.4250/jcvi.2020.0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/09/2020] [Accepted: 09/15/2020] [Indexed: 11/22/2022] Open
Abstract
The Fontan procedure is a well-established surgical technique to improve survival in patients with univentricular heart disease. The procedure reroutes the systemic venous flow to the lungs, bypassing the right ventricle. The originally proposed method involved direct anastomosis of the right atrium to the pulmonary artery. Since then, several modifications have been made in the original technique leading to the modern Fontan, or total cavopulmonary connection. The modern Fontan technique has shown improved surgical outcomes and increased life expectancy in patients with univentricular disease. Due to the increased survival of these patients, long-term complications are becoming more prevalent. Common complications of Fontan procedure include right atrial dilatation and thrombosis; conduit stenosis and thrombosis; right-to-left and left-to-right shunts; hepatic congestion and cirrhosis; and lymphovascular. Computed tomography (CT) can reliably depict the normal Fontan anatomy and various postoperative complications. A fundamental understanding of the techniques of CT, including imaging protocols and common interpretive pitfalls, allows targeted imaging and precise reporting of clinically significant findings. Radiologists should be familiar with the multiple stages of single-ventricle palliation, normal Fontan anatomy, pathophysiology, and imaging features of common Fontan-related complications.
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Affiliation(s)
- Parveen Kumar
- Department of Radiodiagnosis & Imaging, Fortis Escort Heart Institute, New Delhi, India.
| | - Mona Bhatia
- Department of Radiodiagnosis & Imaging, Fortis Escort Heart Institute, New Delhi, India
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21
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Chaturvedi A, Baran TM, Ambrosini R, Krishnamoorthy V. Improving CT assessment for pulmonary hypertension in patients with severe aortic stenosis, correlation with right heart catheterization. Clin Imaging 2021; 77:122-129. [PMID: 33676129 DOI: 10.1016/j.clinimag.2021.01.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 12/27/2020] [Accepted: 01/28/2021] [Indexed: 01/25/2023]
Abstract
PURPOSE To identify CT parameters useful for assessment of pulmonary hypertension (PH) in patients with severe aortic stenosis (AS). MATERIALS AND METHODS Retrospective study of 165 patients who had undergone right heart catheterization (RHC), and CTA of the thorax for preoperative aortic valve replacement (TAVR) planning. These were divided into groups based on mean pulmonary artery (PA) pressure (mPAP) of 25 mm Hg on RHC (85 cases and 80 controls). Diameters of main pulmonary artery diameter (MPAD), left pulmonary artery (LPA), right pulmonary artery (RPA), and maximal long axis and short axis diameters of the right atrium (RA) and ventricle (RV) were measured on the axial plane. Univariate and multivariate statistical analysis was utilized to identify metrics predictive of PH. RESULTS MPAD, LPA, and RPA were higher in subjects with mPAP >25 mm Hg (p < 0.0001 for all). Thresholds of 30.5 mm for MPAD (68.4% sensitivity, 82.7% specificity), and 27.5 mm for LPA and RPA (LPA: 51.9% sensitivity, 78.8% specificity; RPA: 62.0% sensitivity, 78.8% specificity) provided the best discrimination of elevated mPAP. Compared to literature values for MPAD (28.9 mm in men and 26.9 mm in women), these thresholds provide lower sensitivity but greatly increased specificity. Inclusion of RA enlargement to MPAD increased specificity to 98.5%, while inclusion of RV enlargement increased specificity to 100%. CONCLUSION Threshold to identify PH in patients with AS using PA enlargement is higher than previously reported range for normal. Inclusion of RA and RV enlargement improves the ability of CT to more accurately identify PH in patients with AS.
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Affiliation(s)
- Abhishek Chaturvedi
- Imaging Science, University of Rochester Medical Center, Rochester, NY, USA.
| | - Timothy M Baran
- Imaging Science, University of Rochester Medical Center, Rochester, NY, USA
| | - Robert Ambrosini
- Imaging Science, University of Rochester Medical Center, Rochester, NY, USA
| | - Vijay Krishnamoorthy
- Department of Medicine: Cardiology, University of Rochester Medical Center, Rochester, NY, USA
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Pediatric Cardiac CT and MRI: Considerations for the General Radiologist. AJR Am J Roentgenol 2020; 215:1464-1473. [PMID: 33084361 DOI: 10.2214/ajr.19.22745] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Optimized Computed Tomography Angiography Protocol for the Evaluation of Thrombus in Patients with Fontan Anatomy. Pediatr Cardiol 2020; 41:1601-1607. [PMID: 32785745 DOI: 10.1007/s00246-020-02417-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 07/18/2020] [Indexed: 10/23/2022]
Abstract
The Fontan procedure is the final stage in the palliative surgical approach to patients with single-ventricle physiology. These patients have an increased risk for thromboembolic disease in the Fontan circuit, which can be evaluated by chest computed tomography angiography (CTA) in acute settings. However, false-positive results are common secondary to unusual streaming patterns in the Fontan circuit. A biphasic CTA protocol was evaluated for the capability to clearly identify structures of the Fontan circuit that are critical for the evaluation of thromboembolic disease. The study was a retrospective chart review of Fontan patients with a chest CTA scan obtained between 2011 and 2017. Two pediatric cardiologists with additional training in cardiac CT imaging independently reviewed each CTA and awarded one point for each of 5 Fontan circuit structures clearly identified resulting in a score range of 0-5. A score of 0-2 considered not capable, 3-4 partially capable, and 5 capable to clearly identify critical structures of the Fontan circuit. During the study period, 46 CTA scans were performed on 21 patients. Of the CTA scans using a biphasic protocol, 62.5% (10/16) were considered capable to clearly identify all 5 critical structures of the Fontan circuit vs 27% (8/30) of the CTA scans using a monophasic protocol (p = 0.027). Overall our results suggest that the single-site biphasic CTA protocol has greater diagnostic capability to detect the presence of Fontan thromboembolic disease when compared to the more traditional monophasic CTA protocol. Future prospective studies are needed to confirm these findings.
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Siripornpitak S, Goo HW. CT and MRI for Repaired Complex Adult Congenital Heart Diseases. Korean J Radiol 2020; 22:308-323. [PMID: 33289363 PMCID: PMC7909854 DOI: 10.3348/kjr.2020.0895] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 08/21/2020] [Accepted: 09/01/2020] [Indexed: 12/30/2022] Open
Abstract
An increasing number of adult congenital heart disease (ACHD) patients continue to require life-long diagnostic imaging surveillance using cardiac CT and MRI. These patients typically exhibit a large spectrum of unique anatomical and functional changes resulting from either single- or multi-stage palliation and surgical correction. Radiologists involved in the diagnostic task of monitoring treatment effects and detecting potential complications should be familiar with common cardiac CT and MRI findings observed in patients with repaired complex ACHD. This review article highlights the contemporary role of CT and MRI in three commonly encountered repaired ACHD: repaired tetralogy of Fallot, transposition of the great arteries after arterial switch operation, and functional single ventricle after Fontan operation.
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Affiliation(s)
- Suvipaporn Siripornpitak
- Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Hyun Woo Goo
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Misdiagnosis of Pulmonary embolism in a Fontan's patient: When standard protocol CT Pulmonary angiogram is inadequate. Radiol Case Rep 2020; 15:2262-2265. [PMID: 32983296 PMCID: PMC7494590 DOI: 10.1016/j.radcr.2020.08.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/17/2020] [Accepted: 08/19/2020] [Indexed: 11/24/2022] Open
Abstract
Patients who have undergone a Fontan's procedure have an abnormal circulation that presents a unique challenge when performing computed tomography pulmonary angiograms. In a standard imaging protocol, contrast is injected into the upper limb veins that feed into the superior vena cava. In Fontan's patients the Computed tomography pulmonary angiograms bypasses the heart and preferentially fills the right lung, with only a small amount of mixture of contrast and noncontrast blood in the pulmonary arteries. In this article, we present the case of a 35-year-old female complaining of chest and abdominal pain with oxygen saturations of 85% on room air. Computed tomography pulmonary angiograms showed suboptimal imaging of the left lung and apparent filling defects in the right lung suggesting a radiological diagnosis of a pulmonary embolism. The abnormal flow and distribution of contrast in the pulmonary arteries can result in a false positive diagnosis of pulmonary embolism. To overcome this, experts advise using a dual-injection of contrast via upper and lower limb central veins to achieve optimal imaging.
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Raptis DA, Bhalla S. Current Status of Cardiac CT in Adult Congenital Heart Disease. Semin Roentgenol 2020; 55:230-240. [PMID: 32859340 DOI: 10.1053/j.ro.2020.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Balasubramanian S, Joshi A, Lu JC, Agarwal PP. Advances in Noninvasive Imaging of Patients With Single Ventricle Following Fontan Palliation. Semin Roentgenol 2020; 55:320-329. [PMID: 32859348 DOI: 10.1053/j.ro.2020.06.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
| | - Aparna Joshi
- Departments of Radiology, University of Michigan, Ann Arbor, MI
| | - Jimmy C Lu
- Departments of Pediatrics, University of Michigan, Ann Arbor, MI; Departments of Radiology, University of Michigan, Ann Arbor, MI
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Ibe DO, Rapp JB, Whitehead KK, Otero HJ, Smith CL, Fogel MA, Biko DM. Pearls and Pitfalls in Pediatric Fontan Operation Imaging. Semin Ultrasound CT MR 2020; 41:442-450. [PMID: 32980091 DOI: 10.1053/j.sult.2020.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The Fontan operation or the total cavopulmonary connection is a palliative surgery for single ventricle congenital heart disease where the systemic venous return circumvents a pumping chamber and flows directly into the pulmonary circuit. With surgical and medical advances, there has been improvement in life expectancy of these patients, however, it has also resulted in unique complications from the physiology that requires diligent surveillance. A critical component relies on optimal imaging for diagnosis and treatment of these complications. This article describes the normal anatomy of the Fontan circulation, current imaging modalities and techniques, and frequently encountered complications seen when imaging the patients who have undergone Fontan palliation.
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Affiliation(s)
- Donald O Ibe
- Department of Radiology, Silhouette Diagnostic Consultants, Abuja, Nigeria
| | - Jordan B Rapp
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA
| | - Kevin K Whitehead
- Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Hansel J Otero
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christopher L Smith
- Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Mark A Fogel
- Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - David M Biko
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA.
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Radwan S, Gill GS, Ghazzal A, Barnett C. Optimizing Computed Tomography for Detection of Pulmonary Thromboembolism in Patients With Fontan Circulation. Cureus 2020; 12:e8326. [PMID: 32499987 PMCID: PMC7265774 DOI: 10.7759/cureus.8326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Congenital heart disease (CHD) patients who have undergone the Fontan procedure or one of its variants usually have altered vascular anatomy. Consequently, this poses a challenge when diagnosing pulmonary thromboembolism (PTE) with computed tomography (CT). Detailed review of the type of surgery performed and the person’s individual anatomy beforehand can help in choosing the appropriate diagnostic CT modality and technique. It would also help reduce false-positive and false-negative test results that would otherwise result in unnecessary anticoagulation, as well as avoid needless radiation exposure and additional cost, respectively.
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Affiliation(s)
- Sohab Radwan
- Internal Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Gauravpal S Gill
- Internal Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Amre Ghazzal
- Internal Medicine, MedStar Washington Hospital Center, Washington, DC, USA
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Repaired Congenital Heart Disease in Older Children and Adults: Up-to-Date Practical Assessment and Characteristic Imaging Findings. Radiol Clin North Am 2020; 58:503-516. [PMID: 32276700 DOI: 10.1016/j.rcl.2019.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Because of a recent increase in survival rates and life expectancy of patients with congenital heart disease (CHD), radiologists are facing new challenges when imaging the peculiar anatomy of individuals with repaired CHD. Cardiac computed tomography and magnetic resonance are paramount noninvasive imaging tools that are useful in assessing patients with repaired CHD, and both techniques are increasingly performed in centers where CHD is not the main specialization. This review provides general radiologists with insight into the main issues of imaging patients with repaired CHD, and the most common findings and complications of each individual pathology and its repair.
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Approach to Abnormal Chest Computed Tomography Contrast Enhancement in the Hospitalized Patient. Radiol Clin North Am 2020; 58:93-103. [DOI: 10.1016/j.rcl.2019.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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de Lange C. Imaging of complications following Fontan circulation in children - diagnosis and surveillance. Pediatr Radiol 2020; 50:1333-1348. [PMID: 32468285 PMCID: PMC7445207 DOI: 10.1007/s00247-020-04682-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/08/2020] [Accepted: 04/16/2020] [Indexed: 12/27/2022]
Abstract
The Fontan operation is performed for various cardiac lesions with single-ventricle physiology. The survival rate of Fontan patients is increasing for adolescents and young adults, with an expected 30-year survival of >80%. Medical health care providers including specialists in organ systems and pediatric radiologists need to improve their knowledge about the Fontan circulation and the various organ complications to monitor care. In this review the author explains the basic anatomical and functional features of Fontan palliation and gives an overview of the multiple long-term organ complications that might present in the pediatric population. These include decreased physical capacity, ventricular dysfunction, atrioventricular valve regurgitation and arrhythmia, as well as protein-losing enteropathy, plastic bronchitis, growth/bone composition disturbances, renal dysfunction, and the recently recognized and important liver fibrosis (Fontan-associated liver disease). Neuropsychological and behavioral deficits occur frequently. This review focuses on the key role of radiology in making the diagnosis of these complications, monitoring therapy and predicting outcomes in the pediatric age group. The author discusses how and when radiology is important in Fontan patients, as well as how new techniques enabling quantitative measures in imaging with US, MRI and CT are adapted for pediatric use, and how they contribute to urgently needed surveillance strategies.
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Affiliation(s)
- Charlotte de Lange
- Department of Radiology and Clinical Physiology, Queen Silvia Children's Hospital, Rondv.10, S-41516, Gothenburg, Sweden. .,Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway.
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Duerden L, Abdullah H, Lyen S, Manghat N, Hamilton M. Contrast circulation in adult fontan patients using MR Time Resolved Angiography: Application for CT pulmonary angiography. J Cardiovasc Comput Tomogr 2019; 14:330-334. [PMID: 31889659 DOI: 10.1016/j.jcct.2019.12.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 12/20/2019] [Accepted: 12/24/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND When patients with Fontan circulation require a computed tomographic pulmonary angiogram (CTPA), there are significant challenges in achieving adequate contrast opacification due to the altered anatomical connections. This study used Time Resolved Angiography with Interleaved Stochastic Trajectories (TWIST) Magnetic Resonance Angiography (MRA) to examine contrast circulation in a cohort of patients with Fontan circulation who were having routine MRI follow up to inform the contrast timing of any subsequent CT. METHODS This is a single centre, cross-sectional, observational, retrospective study. The time to peak (TTP) signal intensity from the MRA was recorded using regions of interest on the aorta, pulmonary arteries, cavae and Fontan conduit. Patients were grouped by ejection fraction, global longitudinal strain, indexed stroke volume and cardiac index to examine if these cardiac performance parameters affected the mean TTP. Statistical analysis was performed to find the mean TTP for each of the vessels, which was consequently compared between the different cardiac performance parameters. RESULTS 35 patients were included in the study. Mean TTP contrast enhancement was 31s in the thoracic aorta, 46s in the right pulmonary artery, 41s in the left pulmonary artery and 55s in the Fontan conduit. Cardiac performance shows no statistically significant relationship to the peak contrast enhancement whether measured by ejection fraction, global longitudinal strain, stroke volume index or cardiac index. CONCLUSION The mean optimal timing for a single-phase examination of the Fontan circulation, following an upper limb injection, was 55 s following start of contrast injection irrespective of cardiac performance. In TWIST MRA, the IV bolus is 4-5 s duration. A longer bolus is required for CTA, around 20s, suggesting an additional delay will be required. We propose that an optimal single phase CTPA to be protocolled at 70 s following the start of contrast injection, assuming adequate iodinated contrast dose.
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Affiliation(s)
- Laura Duerden
- Bristol Royal Infirmary, University Hospital Bristol NHS Foundation Trust, Bristol, UK
| | - Hazrini Abdullah
- Bristol Royal Infirmary, University Hospital Bristol NHS Foundation Trust, Bristol, UK.
| | - Stephen Lyen
- Bristol Royal Infirmary, University Hospital Bristol NHS Foundation Trust, Bristol, UK
| | - Nathan Manghat
- Bristol Royal Infirmary, University Hospital Bristol NHS Foundation Trust, Bristol, UK
| | - Mark Hamilton
- Bristol Royal Infirmary, University Hospital Bristol NHS Foundation Trust, Bristol, UK
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Hong SH, Goo HW, Maeda E, Choo KS, Tsai IC. User-Friendly Vendor-Specific Guideline for Pediatric Cardiothoracic Computed Tomography Provided by the Asian Society of Cardiovascular Imaging Congenital Heart Disease Study Group: Part 1. Imaging Techniques. Korean J Radiol 2019; 20:190-204. [PMID: 30672159 PMCID: PMC6342752 DOI: 10.3348/kjr.2018.0571] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 09/30/2018] [Indexed: 12/13/2022] Open
Abstract
Optimal performance of pediatric cardiothoracic computed tomography (CT) is technically challenging and may need different approaches for different types of CT scanners. To meet the technical demands and improve clinical standards, a practical, user-friendly, and vendor-specific guideline for pediatric cardiothoracic CT needs to be developed for children with congenital heart disease (CHD). In this article, we have attempted to describe such guideline based on the consensus of experts in the Asian Society of Cardiovascular Imaging CHD Study Group. This first part describes the imaging techniques of pediatric cardiothoracic CT, and it includes recommendations for patient preparation, scan techniques, radiation dose, intravenous injection protocol, post-processing, and vendor-specific protocols.
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Affiliation(s)
- Sun Hwa Hong
- Department of Radiology, Mediplex Sejong Hospital, Incheon, Korea
| | - Hyun Woo Goo
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
| | - Eriko Maeda
- Department of Radiology, The University of Tokyo, Tokyo, Japan
| | - Ki Seok Choo
- Department of Radiology, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - I Chen Tsai
- Congenital Heart Disease Study Group Member of the Asian Society of Cardiovascular Imaging, Taiwan
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Nuffer Z, Baran TM, Krishnamoorthy V, Kaproth-Joslin K, Chaturvedi A. Accuracy of Non-Electrocardiographically Gated Thoracic CT Angiography for Right Atrial and Right Ventricular Enlargement. Radiol Cardiothorac Imaging 2019; 1:e190008. [PMID: 33778516 PMCID: PMC7977741 DOI: 10.1148/ryct.2019190008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 06/30/2019] [Accepted: 07/11/2019] [Indexed: 06/12/2023]
Abstract
PURPOSE To assess the role of long-axis (LA) and short-axis (SA) measurements of the right atrium (RA) and right ventricle (RV) at non-electrocardiographically (ECG) gated thoracic CT angiography for identification of RA enlargement and RV enlargement. MATERIALS AND METHODS This study was a retrospective case review of 138 patients who underwent both non-ECG-gated CT angiography and ECG-gated CT angiography concurrently from November 2016 through November 2018. The SA and LA of the RA and RV were measured by two observers blinded to the ECG-gated CT angiography data. ECG-gated CT angiography-derived RA end-systolic and RV end-diastolic volumes were used as standard of reference to derive cutoff values for diagnosis of RA and RV enlargement. RESULTS In this study, 138 patients were evaluated (70 men, 68 women; mean age, 70.0 years ± 18.4 [standard deviation]; mean body mass index, 29.3 kg/m2 ± 8.1). Of these patients, ECG-gated CT angiography revealed 36.2% had RA enhancement and 19.0% had RV enhancement. The best predictor of RA enhancement was the product of atrial LA and SA measurements, for which a threshold value of 3210 mm2 yielded a 94% sensitivity and 81.8% specificity (area under the curve [AUC], 0.92). A threshold of 55.5 mm for LA diameter had 86% sensitivity and 78.4% specificity in identifying RA enlargement. RV enlargement could be predicted if the SA diameter was greater than 48.5 mm (76.9% sensitivity and 64.9% specificity) and with a body surface area indexed value of 27.0 mm/m2 (92.3% sensitivity and 74.8% specificity [AUC, 0.87]). CONCLUSION RA and RV enlargement can be accurately diagnosed by using non-ECG-gated CT angiography.© RSNA, 2019Supplemental material is available for this article.
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Abstract
Cardiovascular CT (CCT) is an important imaging modality in congenital and acquired paediatric heart disease. Technological advances have resulted in marked improvements in spatial and temporal resolution of CCT with a concomitant increase in speed of data acquisition and a decrease in radiation dose. This has elevated CCT from being sparingly used to an essential diagnostic tool in the daily multimodality imaging practice alongside echocardiography, cardiovascular MR and invasive angiography. The application of CCT in paediatric congenital and acquired heart disease can be both technically and diagnostically challenging. This review highlights important considerations for current state of the art CCT across the spectrum of heart disease encountered in children.
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Affiliation(s)
- Kristian H Mortensen
- 1 Cardiorespiratory Unit, Great Ormond Street Hospital for Children NHS Foundation Trust , London , UK
| | - Oliver Tann
- 1 Cardiorespiratory Unit, Great Ormond Street Hospital for Children NHS Foundation Trust , London , UK
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Rigsby CK, McKenney SE, Hill KD, Chelliah A, Einstein AJ, Han BK, Robinson JD, Sammet CL, Slesnick TC, Frush DP. Radiation dose management for pediatric cardiac computed tomography: a report from the Image Gently 'Have-A-Heart' campaign. Pediatr Radiol 2018; 48:5-20. [PMID: 29292481 PMCID: PMC6230472 DOI: 10.1007/s00247-017-3991-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 08/21/2017] [Accepted: 09/12/2017] [Indexed: 12/28/2022]
Abstract
Children with congenital or acquired heart disease can be exposed to relatively high lifetime cumulative doses of ionizing radiation from necessary medical imaging procedures including radiography, fluoroscopic procedures including diagnostic and interventional cardiac catheterizations, electrophysiology examinations, cardiac computed tomography (CT) studies, and nuclear cardiology examinations. Despite the clinical necessity of these imaging studies, the related ionizing radiation exposure could pose an increased lifetime attributable cancer risk. The Image Gently "Have-A-Heart" campaign is promoting the appropriate use of medical imaging studies in children with congenital or acquired heart disease while minimizing radiation exposure. The focus of this manuscript is to provide a comprehensive review of radiation dose management and CT performance in children with congenital or acquired heart disease.
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Affiliation(s)
- Cynthia K Rigsby
- Department of Medical Imaging #9, Ann & Robert H. Lurie Children's Hospital of Chicago, Departments of Radiology and Pediatrics, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Chicago, IL, 60611, USA.
| | - Sarah E McKenney
- Division of Diagnostic Imaging and Radiology, Children's National Medical Center, Washington, DC, USA
| | - Kevin D Hill
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Anjali Chelliah
- Division of Pediatric Cardiology, Columbia University Medical Center and New York-Presbyterian Hospital, New York, NY, USA
| | - Andrew J Einstein
- Division of Cardiology, Departments of Medicine and Radiology, Columbia University Medical Center and New York-Presbyterian Hospital, New York, NY, USA
| | - B Kelly Han
- Department of Pediatrics, Children's Heart Clinic at The Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
| | - Joshua D Robinson
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Departments of Pediatrics and Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Christina L Sammet
- Department of Medical Imaging #9, Ann & Robert H. Lurie Children's Hospital of Chicago, Departments of Radiology and Pediatrics, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Chicago, IL, 60611, USA
| | - Timothy C Slesnick
- Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Donald P Frush
- Department of Radiology, Duke University Medical Center, Durham, NC, USA
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