Assessment of Double Outlet Right Ventricle Associated with Multiple Malformations in Pediatric Patients Using Retrospective ECG-Gated Dual-Source Computed Tomography

Is combined MDCT and echocardiography needed to guarantee accuracy in diagnosis and surgical planning of DORV and associated anomalies?

Background

The term of Double-outlet right ventricle (DORV) is used to describe a spectrum of complex congenital cardiac malformations where anomalies of the ventriculo-arterial alignment are noted where both great arteries (pulmonary artery and aorta) originate completely or predominantly from the right ventricle. The purpose of this study is to evaluate the diagnostic accuracy of electrocardiography (ECG) gated multidetector computed tomography (MDCT) in preoperative assessment of DORV and its associated malformations, providing key anatomic parameters that affect surgical planning.

Results

A total of 50 patients diagnosed by echocardiography with DORV referred from our institute between September 2018 and August 2020 were enrolled. The location of the ventricular septal defect (VSD) to the great vessels and the alignment of the great vessels to each other as well as other associated malformations that affect the surgical planning were assessed by MDCT. The patients were retrospectively classified into subgroups according to the relative positions of the great arteries, the relationship between the great arteries and the VSD, and the presence of associated malformations according to the classification of Society of Thoracic Surgeons database. The diagnostic value of MDCT and transthoracic echocardiography (TTE) in evaluation of associated cardiac malformations apart from double outlet right ventricle was compared in 20 patients, whom surgeries were performed and surgical results were obtained. Fallot type of DORV was the most common clinical type which represented 48% of the patients in which the VSD is committed to the aorta. The second most common clinical type was Taussig–Bing anomaly which represented 30% of the patients and the VSD was seen committed to the pulmonary artery. The atrio-ventricular septal defect (AVSD)/uni-ventricular type represented 16% of the patients in the current study, with pulmonary and systemic venous anomalies, heterotaxy syndrome and situs anomalies were commonly associated. A total of 53 malformations apart from DORV were found in 20 patients whom performed surgical interventions. MDCT detected different vascular and situs anomalies in those patients with 100% sensitivity and 100% positive predictive value compared to 71.4% and 94% respectively in TTE. On the other hand, in our study TTE was superior to MDCT for detection of intracardiac anomalies with 100% sensitivity and 100% accuracy compared to 87.5% and 95% respectively in MDCT.

Conclusions

Our study suggested that ECG gated MDCT serves as a rapid, noninvasive imaging modality with good spatial resolution and provides excellent diagnostic image quality and has satisfactory diagnostic accuracy in the preoperative assessment of DORV. It is superior to echocardiography in providing a comprehensive mapping of the anatomy of complex anomalies especially that of extra-cardiac structures such as aorta, systemic veins, pulmonary veins, and pulmonary arteries. However, it can miss tiny intracardiac malformations. So combining the results of MDCT and echocardiography would be beneficial to guarantee the accuracy of diagnosis of DORV.

Double outlet right ventricle in adults: Anatomic variability, surgical treatment, and late postoperative complications

Double outlet right ventricle (DORV) is a highly complex congenital heart disease (CHD) entity, gaining increasing interest due to the rapid progress of cardiac surgery. The number of patients operated for this congenital defect has been growing since 1980s and over following decades with active transitioning of this cohort into the adult medicine. However, the diversity of initial anomaly and performed interventions makes challenging the management of these patients. This is particularly important in the regions where specialized adult CHD cardiology still remains underdeveloped. In this review, we observe the basic principles of DORV nomenclature, main types of the operations and possible late complications. The article focuses on adult patients and offers illustrations from clinical practice.

Low-dose Computed Tomography (CT) for the Diagnosis of Congenital Heart Disease in Children: A Meta-analysis

BACKGROUND

Low dose CT has become a promising examination method for the diagnosis of Congenital heart disease (CHD) in children because it has a low radiation dose, but it has not been widely accepted as an alternative to standard-dose CT in clinical applications due to concerns about image quality. Therefore, we suggest that the diagnostic accuracy, image quality, and radiation dose of low-dose CT for CHD in children should be fully explored through a metaanalysis of existing studies.

METHODS

A comprehensive search was performed to identify relevant English and Chinese articles (from inception to May 2019). All selected studies concerned the diagnosis of CHD in children using low-dose CT. The accuracy of low-dose CT was determined by calculating pooled estimates of sensitivity, specificity, diagnostic odds ratio, and likelihood ratio. Pooling was conducted using a bivariate generalized linear mixed model. Forest plots and summary receiver operating characteristic (SROC) curves were generated.

RESULTS

Ten studies, accounting for 577 patients, met the eligibility criteria. The pooled sensitivity and specificity were 0.95 (95% confidence interval (CI) 0.92-0.97) and 1.00 (95% CI 1.00- 1.00), respectively. The pooled diagnostic odds ratio, positive likelihood ratio, and negative likelihood ratio of low-dose CT were 12705.53 (95% CI 5065.00-31871.73), 671.29 (95% CI 264.77- 1701.97), and 0.05 (95% CI 0.03-0.08), respectively. Additionally, the area under the SROC curve was 1.00 (95% CI 0.99-1.00), suggesting that low-dose CT is an excellent diagnostic tool for CHD in children.

CONCLUSION

Low-dose CT, especially with a prospective ECG-triggering mode, provides excellent imaging quality and high diagnostic accuracy for CHD in children.

Imaging Spectrum of Double-Outlet Right Ventricle on Multislice Computed Tomography

Double-outlet right ventricle is a complex congenital heart disease that encompasses various common and rare subtypes. Surgical management of these patients needs to be individualized owing to extremely variable morphology and hemodynamics. Imaging plays a crucial role in determination and characterization of outflow tract morphology. The assessment of ventricular septal defect routability with identification of associated anomalies has therapeutic implications in these patients. Multislice computed tomography with advanced 3-dimensional postprocessing techniques and dose-reduction strategies is invaluable in defining the anatomy and morphology of double-outlet right ventricle with simultaneous assessment of associated anomalies.

Assessment of intracardiac and extracardiac anomalies associated with coarctation of aorta and interrupted aortic arch using dual-source computed tomography

To evaluate the value of dual-source computed tomography (DSCT) compared with transthoracic echocardiography (TTE) in assessing intracardiac and extracardiac anomalies in patients with coarctation of aorta (CoA) and interrupted aortic arch (IAA). Seventy-five patients (63 with CoA and 12 with IAA) who received preoperative DSCT and TTE were retrospectively studied. Intracardiac and extracardiac anomalies were recorded and compared by DSCT and TTE, in reference to surgical or cardiac catheterization findings. A total of 155 associated anomalies were finally found. Collateral circulation (56, 74.70%), patent ductus arteriosus (PDA; 41, 54.67%) were the most common anomalies. PDA, aortopulmonary window, and collateral circulation were more frequently present in patients with IAA than those with CoA (100% vs. 46.03%, 16.67% vs. 0%, and 100% vs. 69.84%, respectively, all p < 0.05). DSCT was superior to TTE in assessing associated extracardiac-vascular anomalies (sensitivity: 100% vs. 39.81%; specificity: 100% vs. 100%; positive predictive value: 100% vs. 100%; negative predictive value: 100% vs. 76.06%). Extracardiac-vascular anomalies, including collateral circulation and PDA, were the most common anomalies in patients with IAA and CoA. Compared with TTE, DSCT is more reliable in providing an overall preoperative evaluation of morphological features and extracardiac anomalies for surgical planning.

Cross-sectional imaging of congenital pulmonary artery anomalies

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

Computed tomography for evaluating right ventricle and pulmonary artery in pediatric tetralogy of Fallot: correlation with post-operative pulmonary regurgitation

Pulmonary regurgitation (PR) is the most common complication after tetralogy of Fallot (TOF) surgical repair, and long-term PR might result in cardiovascular events. The aim of this study was to assess the influence of pre-operative right ventricle (RV) and pulmonary artery (PA) parameters assessed by dual-source computed tomography on post-operative PR. A total of 41 TOF patients who underwent trans-valve surgical repair were retrospectively recruited. The RV and PA parameters evaluated by pre-operative DSCT were compared between the PR and non-PR groups. Our result revealed that the PA parameters (McGoon ratio, Nakata index, and LPA diameter) and RV parameters (RV length diameter and RV short diameter) all showed significant differences between the two groups (all p < 0.05). There was a significant correlation between PR and LPA diameter (r = 0.361), McGoon ratio (r = 0.413), and Nakata index (r = 0.482). Receiver operating characteristic analysis also revealed a moderate sensitivity and specificity of LPA (66.33%; 82.60%), McGoon ratio (83.33%, 56.52%), and Nakata index (83.33%; 60.87%) for predicting the occurrence of PR. This study indicated that these pre-operative indices calculated by DSCT are associated with post-operative PR and that these pre-operative PA and RV parameters may serve as novel predictors of the risk of PR.

Assessment of tetralogy of Fallot-associated congenital extracardiac vascular anomalies in pediatric patients using low-dose dual-source computed tomography

Background

To investigate the diagnostic value of dual-source computed tomography (DSCT) in the evaluation of tetralogy of Fallot (TOF)-associated extracardiac vascular abnormalities in pediatric patients compared with transthoracic echocardiography (TTE).

Methods

One hundred and twenty-three pediatric patients diagnosed with TOF were included in this retrospective study. All patients underwent DSCT and TTE preoperatively. All associated extracardiac vascular abnormalities and their percentages were recorded. The diagnostic performances of DSCT and TTE were compared based on the surgical results. The image quality of DSCT was rated, and the effective radiation dose (ED) was calculated.

Results

A total of 159 associated extracardiac vascular deformities were confirmed by surgery. Patent ductus arteriosus (36, 22.64%), right-sided aortic arch (29, 18.24%), and pulmonary valve stenosis (23, 14.47%) were the most common associated extracardiac vascular abnormalities. DSCT was superior to TTE in demonstrating associated extracardiac anomalies (diagnostic accuracy: 99.13% vs. 97.39%; sensitivity: 92.45% vs. 77.07%; specificity: 99.81% vs. 99.42%). The agreement on grading the image quality of DSCT was excellent (κ = 0.80), and the mean score of the image quality was 3.39 ± 0.50. The mean ED of DSCT was 0.86 ± 0.47 mSv.

Conclusions

Compared to TTE, low-dose DSCT has high diagnostic accuracy in the depiction of associated extracardiac vascular anomalies in pediatric patients with TOF, and could provide more morphological details for surgeons.

Dual-source Computed Tomography for Evaluating Pulmonary Artery and Aorta in Pediatric Patients with Single Ventricle

To explore the accuracy of main pulmonary artery (MPA) and ascending aorta (AAO) image evaluation in pediatric patients with single ventricle (SV) by comparing dual-source computed tomography (DSCT) with echocardiography. Thirty-one children with SV were retrospectively enrolled. The stenosis, dilation, and location of MPA and AAO were independently evaluated by DSCT and echocardiography. The accompanying arterial malformations were also assessed by DSCT. For 17 patients undergoing cardiac catheterization, the DSCT-based diameters of MPA and AAO were correlated with their pressures as measured by catheterization. Referring to the surgical and catheterization findings, DSCT had better diagnostic performance in detecting the stenosis, dilation, and location of MPA and AAO with higher sensitivity than echocardiography (sensitivity, MPA: 88.0% vs. 80.0%, AAO: 100% vs. 66.7%, great arteries location: 95.7% vs. 95.2%). The correlations between diameters of MPA and AAO with their pressures were 0.399 (p = 0.04) and 0.611 (p = 0.01), respectively. In addition, DSCT detected 23 cases with patent ductus arteriosus, 26 systemic-to-pulmonary collaterals, 9 branch pulmonary distortions, and 4 coronary artery anomalies. DSCT is reliable for assessing the anatomic features of pulmonary artery and aorta in SV children, and provides comprehensive information for surgical strategy-making.

Double-outlet right ventricle with an intact interventricular septum and concurrent hypoplastic left ventricle in a calf

A 3-day-old Hereford heifer calf presented for evaluation of lethargy and dyspnea, with persistent hypoxia despite supplemental oxygen therapy. A grade III/VI right apical systolic murmur was noted during cardiac auscultation. Echocardiography revealed a double-outlet right ventricle with an intact interventricular septum and concurrent hypoplastic left ventricle and tricuspid valve dysplasia. Post-mortem examination revealed additional congenital anomalies of ductus arteriosus, patent foramen ovale, and persistent left cranial vena cava. This report illustrates the use of echocardiographic images to diagnose a double-outlet right ventricle with an intact interventricular septum and a hypoplastic left ventricle in a calf.

Dual-source computed tomography for evaluating pulmonary artery in pediatric patients with cyanotic congenital heart disease: Comparison with transthoracic echocardiography

PURPOSE

To evaluate the quantitative accuracy of dual-source computed tomography (DSCT) on measurements of pulmonary artery in pediatric patients with cyanotic congenital heart diseases (CCHDs) when compared with transthoracic echocardiography (TTE).

METHODS

Thirty-five patients (mean age: 27.88 ± 28.27 months) with CCHDs underwent DSCT and TTE for evaluating the diameter of the main pulmonary artery (MPA), right pulmonary artery (RPA), and left pulmonary artery (LPA). Surgical measurements were obtained and served as the reference standard. The agreement was tested by linear regression analysis, Pearson's correlation coefficient, and Bland-Altman analysis. The intra- and extracardiac malformations were also observed.

RESULTS

There was a markedly positive correlation between DSCT and surgical measurements of the MPA, RPA, and LPA (r=0.95-0.97; all p<0.001), although the overestimation of the measurements of MPA, RPA, and LPA (bias 0.15 ± 0.95, 0.31 ± 0.63 and 0.35 ± 0.68 mm, respectively) was observed. However, there was a moderate correlation between TTE and surgical measurements of MPA, RPA, and LPA (r=0.61-0.84; all p<0.001), and the underestimation of the measurements of MPA, RPA, and LPA (bias-1.20 ± 1.69, -1.80 ± 1.77, and -1.50 ± 2.30 mm, respectively) was observed. In addition, DSCT was more efficient in finding associated malformations than TTE (40/40 vs. 33/40).

CONCLUSIONS

As a reliable, noninvasive and radiation-save imaging modality, DSCT can provide more accurate pulmonary artery measurements than TTE in cardiac surgical procedures.