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