role of ct and mr in fallot disease
TRANSCRIPT
ElieMousseaux
GillesSoulatFrancescaPitoccoEtienneCharpentier
RoleofCTandMRinFallotdisease
Conflict of Interest from 2014 to 2018
ElieMousseaux
Nolinkorconflictwiththefollowingpresentation
Background
Chiuetal.CircCardiovascQualOutcomes2012
Background
• Predictorsofoutcome:• RVhypertrophy• RVdysfunction• LVdysfunction• Atrialtachyarrhythmia
Valenteetal.Heart2014
• ESC2010guidelinesClassIIa/LevelCPVRshouldbeconsideredinasymptomaticpatientswithseverePRwhenatleastoneofthecriteriaispresent:
• Decreaseinobjectiveexercise• ProgressiveRVdilatation• ProgressiveRVdysfunction• Progressivetricuspidregurgitation• Sustainedatrial/ventriculararrhythmias
Role of CMR
• Rolevariesaccordingageandclinicalcircumstance• Firstdecade:TTEisalmostsufficient.CMRisnotrecommendedroutinely• After,CMRisrecommendedforRVsize,functionandpulmonaryregurgitation.
• Echographywindowsmorerestricted• Adverseclinicaloutcomeincreases• NosedationforCMRinadolescentsandadults
Valenteetal.JASE2014.
MR Scanning/Reports elements
RVandLVvolumes,mass,SVandEF
Wallmotionabnormalites
AnatomyofRVOT,PA,aorta
QuantificationofPR,TR,CardiacoutputanQP/QS
Viability
RV size and function
Gevaetal.JCMR2011
Background
Oosterhofetal.Circulation2007
RV size and function
Gevaetal.JCMR2011
LV function
• Impairedin20%ofFallotdisease.Strongprognosticfactor.
Gevaetal.JACC2004
Anatomy of RVOT
3DSSFPSequence:ECGgated,andMPRpossible.2DSSFP:usefulforwallmotionassessment3DMRA:nonsynchronized:motionartefact.TSE:lesssensitivetometallicartifact.Importantelementforplanningpercutaneousimplantation
RVOT
Anatomy of PA
• Magneticresonanceangiography• Evaluationofbranchstenosis
Quantification of PR
Anatomy of aorta
• Rightaorticarchin25%ofpatients
Cardiac output and QP/QS
QP=4.03ml;QS=4.12ml
Late Gadolinium Enhancement
• ProposedrecommendationforLGEevaluation:• FirstCMRexamination• >3yearssincelastLGEevaluation• Deteriorationinclinicalstatus• Worseregionalorglobalventricularfunction
Occursin• Locationofpriorsurgery• Ubiquitusinsuperiorandinferiorjunction
Relationwithmortalityremainsunclear
Valenteetal.JASE2014.
Other issues in CMR
• Coronaryanatomy
• ImportantbeforepercutaneousPVimplantation
• CTincaseofsuspectedabnormaloriginand/ortract
• Relationshipwithsternum
Ao PA
Advantages of 4D vs 1D
VMaxFonctiondesonorientationFonctiondudébitsousjacent
JMRI1015
Tetralogy of Fallot with 4D f
RF = 45% No shunt Qp/Qs = 1
CMR limits / Role of CT
• LimitsofCMR• Cost(comparisonwithTTE)• Noportability• Availability• Artifactforimplantswithstainlesssteel• ContraindicationforPManddefibrillator
RoleofCT
Excellentspatialresolution:coronaryarteryanddistalpulmonarybranches
CT
• LimitsofCT• Ionisingradiation• Lowertemporalresolution• Nonhemodynamicinformationonflowrateandvelocity• Riskofcontrastinpatientwithimpairedrenalfunction.
• Giventheyoungageofthispopulation,MDCTshouldbereservedinpatientswithabsolutecontraindicationtoCMR
• SpecificTASK=endocarditisafterPulmonaryValveReplacement
Endocarditis in Fallot Disease and CT
Take home messages
• InFallotdisease,CMRisthereferencestandardforquantificationof
• RVsize• RVfunction• Pulmonaryregurgitation
• OtherinformationprovidedbyCMR:LVfunction,myocardialfibrosis,Anatomyofpulmonarytreeandaorta.
• CTshouldbereservedinpatientwithCItoCMR,andisnotablyusefulforstentvisualizationandcoronaryanatomy