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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3612_Библиотеки_им_академика_М_И_Перельмана
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180
Key Questions in CONGENITAL CARDIAC SURGERY
A
B
C
Aortic root
Figure 9. Computed tomography
images of a patient with tetralogy of
Fallot demonstrating: A) and B) a
thickened pulmonary valve; and C)
hypoplastic but confluent main
pulmonary artery, subaortic ventricular
septal defect and an overriding aorta.
5 Congenital cardiac imaging
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AB
C
D
181
E
Figure 10. Computed tomography in a patient with tetralogy of Fallot
demonstrating: A) a dilated aortic root and right-sided aortic arch; B)
subaortic ventricular septal defect; C) severely stenotic proximal left
pulmonary artery; D) prominent major aortopulmonary collateral arteries
(MAPCA) from the descending aorta to the left lung on volume-rendered
images; and E) a calcified but patent right ventricular outflow tract.
182
Key Questions in CONGENITAL CARDIAC SURGERY
A
Bioprosthesis
B
Bioprosthesis
C
Figure 11. ECG-gated computed
tomography angiography in a patient
with a failing pulmonary valve
bioprosthesis demonstrating the close
relationship of the left coronary artery
(LCA) to the pulmonary artery and
bioprosthesis on: A) double oblique
multiplanar projection; and B) volumerendered image; and C) the close
proximity of the dilated right ventricle to
the sternal manubrium.
5 Congenital cardiac imaging
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pulmonary regurgitation and RV ejection fraction in order to
determine the optimal timing for pulmonary valve replacement. In the
presence of significant pulmonary regurgitation, progressive RV
enlargement or reduced ventricular function detected by serial CMR
are among the indications for pulmonary valve replacement.
Delayed contrast enhancement imaging can identify ventricular
•
scarring and fibrosis at the right ventricular surgical site or LV
myocardium, which has been shown to have an adverse effect in
prognosis.
8 What are the principles of assessing double-outlet right
ventricle with radiological imaging?
In double-outlet right ventricle (DORV), MRI provides complementary
•
and important information on intracardiac anatomy, right and left
ventricular function, the feasibility of intracardiac repair, and the
morphology of the pulmonary arteries and aortic arch (Figure 12).
AB
183
Figure 12. Cardiac magnetic resonance imaging T2-weighted sequence
demonstrating: A) a grossly enlarged right atrium with stagnation of flow;
and B) mid-wall fibrosis of the septum and left ventricular apex in late
gadolinium sequences.
CT can also determine the relationship of the great arteries to the RV,
•
assess the location of the ventricular septal defect, and the presence
and extent of obstruction of the pulmonary and aortic outflow tracts
(Figure 13).
CT and MRI can be used in ruling out extracardiac associated
•
anomalies, including anomalous venous return, aortic coarctation,
interrupted aortic arch and persistent ductus arteriosus. 3D
184
Key Questions in CONGENITAL CARDIAC SURGERY
AB
CD
Figure 13. Computed tomography images in a patient with double-
outlet right ventricle, tricuspid atresia and transposition of the great
arteries demonstrating: A) the side-by-side great arteries, a large
bulboventricular ventricular septal defect (connecting a small right
ventricle to the left ventricle); B) outflow from the right ventricle to the
anteriorly located aorta and kinking of the aortic isthmus (with no
anatomical obstruction); C) a grossly enlarged right atrium with a large
filling defect (consistent with thrombus) on the venous phase image; and
D) a patent right coronary artery in close proximity to the sternum on
curved multiplanar reconstruction.
5 Congenital cardiac imaging
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multiplanar reconstruction allows better demonstration of the
anatomy which can help improve surgical planning.
CT is also useful in detecting coronary artery anomalies, including
•
anomalous origin of the right coronary artery (RCA) from the left main
coronary artery (LMCA), duplication of the left anterior descending
coronary artery (LAD), anomalous origin of the LAD or left circumflex
artery from the RCA, and a single right or left coronary artery.
Whilst most post-interventional imaging is carried out by
•
echocardiography, MRI and CT can offer valuable information when
more precise assessment of RV function or evaluation of residual
outflow or conduit obstruction are needed.
9 What are the principles of assessing transposition of the
great arteries with radiological imaging?
Chest radiograph often shows a narrow mediastinal shadow owing
•
to the parallel relationship of the great arteries (Figure 14). The
cardiothoracic ratio is normal in a patient without ventricular dilation,
and pulmonary vascular markings are normal in the absence of
pulmonary hypertension.
Following an atrial switch procedure, MRI allows quantitative
•
assessment of right and left ventricular systolic function, and serial
measurements of systemic right ventricular function.
185
Figure 14. Chest radiograph in a patient with
transposition of the great arteries demonstrating a
narrow upper mediastinum, due to the central
configuration of the aorta and pulmonary artery.
186
Key Questions in CONGENITAL CARDIAC SURGERY
In addition, the baffle anatomy can be assessed and any shunt
•
across a baffle leak can be quantified.
As many of these patients have a pacemaker, CT is sometimes
•
preferred over MRI, where postoperative anatomy, baffle obstruction
and leaks, and vena cava obstruction can be evaluated efficiently
(Figure 15).
AB
C
Figure 15. Contrast-enhanced computed tomography scans of an
adult patient with transposition of the great arteries who had undergone
a Mustard procedure in infancy, demonstrating a widely patent stent in
the superior vena cava baffle (arrow) on: A) early; and B) late phase
images; and C) occluded and partially calcified inferior vena cava
baffle (arrow).
5 Congenital cardiac imaging
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Following a Rastelli operation, up to 25% of these patients have
•
evidence of left ventricular dysfunction at late follow-up. Right
ventricular dysfunction is also common, as is conduit dysfunction
subsequent to the pressure and/or volume overload. MRI is useful in
serial quantitative assessment of right and left ventricular systolic
function and conduit function. CT can show the conduit patency,
calcification, stenosis and LVOT obstruction and branch pulmonary
artery stenosis in these patients (Figure 16).
AB
187
C
Figure 16. ECG-gated computed tomography angiography in a patient
with transposition of the great arteries, who had previously undergone a
Rastelli procedure, with: A) the coronal image demonstrating a diffusely
calcified pulmonary conduit (arrow) with a small low attenuation vegetation
attached to the bioprosthetic pulmonary valve; B) axial; and C) sagittal
images demonstrating the close proximity of the conduit to the sternal wires.
Key Questions in CONGENITAL CARDIAC SURGERY
Following an arterial switch operation with Lecompte procedure,
•
surgical complications include pulmonary outflow obstruction and
branch pulmonary artery stenosis, neo-aortic root dilatation and valve
regurgitation, and coronary artery stenosis.
In these patients, other than quantifying ventricular volumes, MRI is
•
useful in assessing valve function, such as the severity of aortic
regurgitation. The anatomy of the branch pulmonary arteries and
coronary arteries can be defined by MRI, as well as evaluating the
myocardial perfusion and viability (Figure 17).
188
A
B
Figure 17. Magnetic resonance angiography demonstrating the
pulmonary arteries straddling the aorta following an arterial switch
procedure and Lecompte manoeuvre, with narrowing of the left pulmonary
artery (arrow) due to compression from the ascending aorta and a mildly
dilated sinus of Valsalva (arrowhead) on: A) axial b-SSFP; and B) volumerendered images.
CT is useful in further anatomical delineation, exclusion of branch
•
pulmonary artery stenosis and investigation for coronary artery stenosis.
10 What are the principles of assessing congenitally
corrected transposition of the great arteries with
radiological imaging?
Chest radiograph in patients with congenitally corrected
•
transposition of the great arteries (ccTGA) may demonstrate
dextrocardia or mesocardia.
MRI is a useful modality in patients with ccTGA and following surgery
•
for assessment of:
5 Congenital cardiac imaging
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a) anatomy and ventricular function;
b) myocardial ischaemia or scarring;
c) RV size and function;
d) tricuspid regurgitation severity.
Cardiac CT allows excellent anatomical assessment of the cardiac
•
chambers, great vessels and coronary arteries, as well as
determination of cardiac function (Figure 18).
AB
PC
RPA
189
C
PC
Figure 18. Computed tomography images of a patient with congenitally
corrected transposition of the great arteries, who had previously undergone an
anatomical left ventricle (LV) to pulmonary artery (PA) conduit, and closure of
atrial and ventricular septal defects, demonstrating: A) a heavily calcified LVPA conduit; B) a right-sided ventricle connected to a posteriorly located
pulmonary artery with stenosis at the subpulmonary level (arrow); and C) the
position of the conduit in relation to the sternum. PC = pulmonary conduit.
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