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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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Key Questions in CONGENITAL CARDIAC SURGERY
AB
C
200
E
D
F
Figure 26. Computed tomography (CT) images used to plan transcatheter
valve implantation for a patient with tetralogy of Fallot and significant pulmonary
homograft valve regurgitation. CT can help to choose the appropriate size and
type of device, measure the length and diameter of the homograft, location of
the homograft in relation to the coronary arteries and to map venous access,
especially when venous stenosis or thrombosis is suspected.
19 What are the principles of assessing vascular slings and
rings with radiological imaging?
Since patients with vascular slings and rings often present with
•
respiratory symptoms, chest radiograph may be the initial imaging
step, with findings such as tracheal narrowing or unilateral aeration.
5 Congenital cardiac imaging
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Upper GI fluoroscopy in a patient with dysphasia may demonstrate
•
indentation of the oesophagus in the lateral view.
CTA and MRA can both demonstrate the vascular structure in precise
•
relation to extra-vascular anatomy (Figure 27). Gated CTA or CMR can
delineate any intracardiac-associated anomalies (Figure 28).
201
Figure 27. Volume-rendered computed
tomography angiography image (posterior
view) demonstrating a right dominant
double aortic arch, resulting in localised
narrowing of the trachea (arrow).
A B
Figure 28. Computed tomography angiography images demonstrating:
A) a left pulmonary artery sling, as well as a narrow and circular distal
trachea and proximal main bronchi, suspicious for complete cartilage
rings; and B) an over-inflated right lung and resulting mediastinal deviation.
Key Questions in CONGENITAL CARDIAC SURGERY
20 What are the principles of assessing an
aortopulmonary connection with radiological
imaging?
CT scanning can be used to delineate the anatomical features of
•
aortopulmonary window with an abnormal connection between the
aorta and the pulmonary trunk, as well as associated anomalies
related to pulmonary hypertension (Figure 29).
AB
Asc Ao
202
C
PA
RV
D
PA
Figure 29. Computed tomography angiography images demonstrating: A)
a large connection between the mid-segments of the pulmonary artery (PA)
and ascending aorta (Asc Ao); B) the aortopulmonary connection and
dilated hepatic veins (arrow) as a result of increased right heart pressures; C)
pulmonary artery dilatation; and D) secondary mosaic perfusion changes in
the lung, secondary to pulmonary hypertension. RV = right ventricle.
courtesy of Dr. Tom Semple, Consultant Radiologist, Royal Brompton Hospital, London,
UK.
PA
Images
5 Congenital cardiac imaging
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Recommended reading
1. Di Salvo G, Miller O, Babu Narayan S, Li W, Budts W, Valsangiacomo Buechel ER,
Frigiola A, van den Bosch AE, Bonello B, Mertens L, Hussain T, Parish V, Habib G,
Edvardsen T, Geva T, Baumgartner H, Gatzoulis MA; 2016-2018 EACVI Scientific
Documents Committee. Imaging the adult with congenital heart disease: a
multimodality imaging approach - position paper from the EACVI.
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2. Yeong M, Loughborough W, Hamilton M, Manghat N. Role of cardiac MRI and CT in
Fontan circulation.
3. Qureshi MY, O’Leary PW, Connolly HM. Cardiac imaging in Ebstein anomaly.
`~кЗбзо~лЕ=jЙЗ
4. Sachdeva R, Valente AM, Armstrong AK, Cook SC, Han BK, Lopez L, Lui GK,
Pickard SS, Powell AJ, Bhave NM, Sachdeva R, Valente AM, Pickard SS, Baffa JM,
Banka P, Cohen SB, Glickstein JS, Kanter JP, Kanter RJ, Kim YY, Kipps AK, Latson
LA, Lin JP, Parra DA, Rodriguez FH 3rd, Saarel EV, Srivastava S, Stephenson EA,
Stout KK, Zaidi AN. ACC/AHA/ASE/HRS/ISACHD/SCAI/SCCT/SCMR/SOPE
2020 Appropriate Use Criteria for Multimodality Imaging During the Follow-Up Care
of Patients With Congenital Heart Disease: A Report of the American College of
Cardiology Solution Set Oversight Committee and Appropriate Use Criteria Task
Force, American Heart Association, American Society of Echocardiography, Heart
Rhythm Society, International Society for Adult Congenital Heart Disease, Society for
Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed
Tomography, Society for Cardiovascular Magnetic Resonance, and Society of
Pediatric Echocardiography.
2018; 19(10): 1077-98.
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2018; 28(6): 403-9.
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2017; 1(1): 8.
2020; 75(6): 657-703.
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203
204
Key Questions in CONGENITAL CARDIAC SURGERY
Chapter 6
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Congenital angiography and
catheter interventions
Jenny E. Zablah, Neil Wilson
1 What are the factors that may contribute to higher
radiation exposure on patients undergoing cardiac
catheterisation?
Factors such as age, body size, distance between the X-ray
•
generator and the body, length of the study and frame rate of
fluoroscopy and image acquisition contribute to the level of
exposure.
Tactics to decrease radiation dose and improve image quality
•
include:
a) adequate positioning, with patients iso-centred and straight
on the table;
b) using the lowest acceptable frame rate during pulsed
fluoroscopy and cine angiography;
c) avoid exposing unnecessary body parts, such as arms and
skull from the field;
d) using the lowest acceptable magnification mode;
e) using collimators and filters;
f) centring the region of interest correctly in the field;
g) keeping the image intensifier as close to the patient as
possible and the X-ray tube as far away as possible;
h) using the angiographic projection that reduces operator
exposure;
i) minimising beam-on time;
j) removing anti-scatter grids when catheterising small children
(<20kg).
205
206
Key Questions in CONGENITAL CARDIAC SURGERY
2 What are the potential hazard factors of higher
radiation exposure during cardiac catheterisation?
Radiation-induced skin reaction — which may not appear until 2-3
•
weeks after exposure, where:
a) the threshold for mild transient skin erythema is 2Gy;
b) erythema and hair loss are expected with peak skin doses
exceeding 6Gy;
c) doses of 10-15Gy may cause telangiectasis and chronic skin
changes;
d) higher exposure may cause skin ulceration.
Radiation eye injury — where high doses of radiation can damage the
•
conjunctiva, iris, sclera and blood vessels of the retina. The lens may
sustain irreversible damage from a relatively low dose of radiation
with resulting formation of cataracts. For this reason, operators are
advised to wear protective goggles.
Malignancy — where there is no clear exposure threshold for the
•
development of malignancy after radiation exposure. This is defined
as a stochastic effect, which is nevertheless dose-related. Most
radiation-induced damage is rapidly repaired but occasional
misrepair of DNA breaks can result in point mutations, chromosomal
translocations and gene fusions linked to the induction of cancer. The
organs with higher risk include the brain, skin and thyroid. For this
reason, operators are advised to wear a full body shield, and a
thyroid shield.
3 What are the commonest two-dimensional biplane
angiographic projections used for congenital heart
disease?
The main goal with any view is to get an axial, non-overlapped or non-
•
foreshortened profile of the chamber or vessel in question.
In the angiographic interrogation of congenital heart disease, many
•
different projections may be needed in the context of situs, position
of the heart and the underlying anatomy.
There are several recommended projections for specific defects but
•
the choice of a set of projections will depend upon the information
required, equipment capabilities and personal operator preferences
(Table 1 and Figure 1).
6 Congenital angiography and catheter interventions
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Table 1. Angiographic projections used for specific vessels and lesions.
iЙлбзе
Pulmonary stenosis
Right ventricular outflow tract and
main pulmonary artery
Long axial view of the left
pulmonary artery
Atrial septal defect
Pulmonary artery bifurcation
and branches
Left ventricular outflow tract obstruction
Coarctation of the aorta
Ventricular septal defect
Patent ductus arteriosus
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0° + 30° cranial
10° LAO + 40° cranial
30° RAO
30° LAO + 30° cranial
30° caudal + 10° RAO
RAO
RAO 45-70°
30° RAO
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90°
90°
60° LAO + 30° cranial
20° caudal
60° LAO + 20-30° cranial
90° or 60° LAO + 20-30°
cranial
207
LAO + 30° cranial
90°
AB
Ao
VSD
LV
Ao
RV
Figure 1. Standard angiographic views used for a ventricular septal defect:
A) right anterior oblique (RAO) view ventricular angiogram demonstrating a
ventricular septal defect (VSD) in a patient with mirror image dextrocardia; B)
50° left anterior oblique (LAO) + 30° cranial view ventricular angiogram
demonstrating a ventricular septal defect (VSD) in a patient with levocardia.
LV = left ventricle; RV = right ventricle; Ao = aorta.
VSD
LV
208
Key Questions in CONGENITAL CARDIAC SURGERY
4 Describe the principles of three-dimensional rotational
angiography
Three-dimensional rotational angiography (3DRA) is used in the
•
guidance of various transcatheter therapies, including but not
exclusive to percutaneous pulmonary valve implantation, coarctation
stent placement, anatomical evaluation of single-ventricle palliation,
pulmonary artery anatomy and others.
Rotational angiographic images are acquired with C-arm rotation in
•
the axial plane over 3-5 seconds (depending on the system).
During the C-arm rotation, a timed contrast injection is performed to
•
uniformly opacify the vascular anatomy for the duration of the image
acquisition.
This image is dynamic and demonstrates cardiac structures in a
•
three-dimensional perspective that allows measurements to be made
throughout the cardiac cycle and may be used as reference imaging
for interventions (Figure 2).
AB
*
Figure 2. Three-dimensional angiographic reconstructions
demonstrating a: A) transverse arch aneurysm (*); and B) ascending
aortic compression with balloon inflation in the right ventricular outflow
tract during coronary artery assessment in the preparation for
transcatheter pulmonary valve intervention.
The reconstruction of the 3D image volume set occurs immediately
•
after the rotation is complete, requiring <30 seconds to be generated
but it will still require manual work to optimise the information
obtained.
6 Congenital angiography and catheter interventions
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These reconstruction images, once generated, can be rotated in 3D
•
to determine the optimal views of the anatomy of interest.
3D image fusion software is available which extends the 3DRA
•
technology to use pre-registered computed tomography or magnetic
resonance imaging datasets. This allows live guidance of an
interventional procedure with a 3D roadmap overlay with or without
marking points (Figure 3). These different resources and
technologies may reduce contrast and radiation exposure and result
in shorter procedural times.
AB
RBCA
LCCA
LSCA
Figure 3. Three-dimensional image fusion of the aortic arch with live
angiography prior to stent deployment in a coarctation demonstrating: A) the
left subclavian artery that has been marked to serve as a distal point for stent
positioning (arrow); and B) positioning of a stent (arrow), which has been
inserted via the femoral artery, prior to deployment in the descending aorta.
RBCA = right brachiocephalic artery; LCCA = left common carotid artery;
LSCA = left subclavian artery.
209
5 What are the characteristics of a normal right atrial
waveform and causes of an abnormal right atrial
tracing?
The normal mean right atrial (RA) pressure is 2-8mmHg. There are
•
two major positive waves (a and v) and two negative descents (x and
y) (Figure 4).
The a wave results from right atrial contraction, follows the P wave
•
on the surface electrocardiogram (ECG) and usually is the dominant
wave. It may be absent in patients with atrial fibrillation or flutter.
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