segmental approach and evaluation of cardiac … - krishnamurthy... · segmental approach and...
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Rajesh KrishnamurthyEB Singleton Dept. of Diagnostic Imaging
Texas Children’s Hospital,Baylor College of Medicine
Houston, TX
Segmental approach And EvaluationOf Cardiac Morphology InCongenital Heart Disease
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Segmental Approach to the Heart
• Any imaginable combination of atrial,ventricular and great vessel morphologycan and does occur in congenital heartdisease
• A simple, logical, step-by-step approachis essential to understanding anddescribing CHD
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Segmental Approach to the HeartLayout of a 3-storied house
• 3 floors (Major Segments)
– Viscero-atrial situs
– Ventricular loop
– Conotruncus
Or, more simply:
– Atria
– Ventricles
– Great Arteries
• 2 staircases (Segmental Connections)
– AV junction
– Conus or Infundibulum
• 2 Entrances
– Systemic veins
– Pulmonary Veins
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Steps in the segmental approach to heart disease
• Anatomic type of each of the 3 major segments. Forexample {S,D,D}, {I,L,L}, {S,D,L} etc.
• How each segment is connected to the adjacent segment(CAVC, DILV, TGA etc. )
• Associated anomalies within each segment, or betweenthem (TAPVR, ASD, VSD, cleft mitral valve etc.)
• How the segmental combinations and connections, with orwithout the associated malformations, function
Accurate anatomical and physiological diagnosis allowsselection of therapeutic options: medical, surgical, or both.
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Steps in the segmental approach to heart disease
Anatomic type of each of the 3 major segments• Atria, Ventricles and Great arteries
• Segmental set {S,D,S} provides a shorthand description ofthe floor-plan of the heart
• Right and left do not refer to the side of the body, but tospecific morphologic criteria that identify each componentof the heart
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Viscero-atrial Situs
• Situs refers to the position of the atria andviscera relative to the midline
• Three types: solitus, inversus, ambiguous
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Atrial Identification
• Receives IVC
• Receives coronary sinus
• Broad based triangularappendage with pectinatemuscles extending intobody of RA
• (Receives SVC)
• Narrow based fingerlike atrial appendage
• (Receives pulmonaryveins)
Right Atrium Left Atrium
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IVC as a marker of the RA
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Morphology of atrial appendages on MRI
Triangulartrabeculated broadbased RAA
Tubularsmooth narrowbased LAA
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Ventricles
• Moderator band
• Septal attachment ofAV valve is moreapical
• Infundibulum (conus)
• No moderator band
• Smooth septal surface
• Septal attachment ofAV valve is morecranial
• No conus
Right Ventricle Left Ventricle
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Ventricles
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L LoopD Loop
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Great Arteries
• Branches to the lungs
• No branch to the body
• Branches to the body
• Coronary artery
Pulmonary artery Aorta
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Lt
SInversus (I)Solitus (S)
Great Arterial Relations
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D-malposition
Great Arterial Relations
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L-malposition
Great Arterial Relations
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Segmental possibilities at each level
• Atria: S, I, A
• Ventricles: D, L
• Great Arteries: S, I, D, L
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SegmentalCombinations
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Segmental Connections: AV Connection
• Biventricular AV connections
• Univentricular AV connections
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Biventricular AV connections
Concordant Discordant
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Common AV Canal
AV connections
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Univentricular
AV connections
• Absent left AVconnection
• Absent right AVconnection
• Double inlet LV
• Double inlet RV
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Double inlet leftventricle
Tricuspid atresia
Univentricular AV connections
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VA connection: Conus
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Conus in D - TGA
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Conus in L - TGA
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Infradiaphragmatic TAPVR
Bilateral SVC
Associated Anomalies:Systemic Veins and Pulmonary Veins
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Physiology
• Too much Pressure (Afterload)
– Right sided obstruction
– Left sided obstruction
• Too much Volume (Preload)
– Left to right shunts
– Valvular incompetence
• Intermixing: Right to left shunts / cyanosis
• Poor contractility: Bad myocardium
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Steps in the segmental approach to heart disease
• Anatomic type of each of the 3 major segments. Forexample {S,D,D}, {I,L,L}, {S,D,L} etc.
• How each segment is connected to the adjacent segment(CAVC, DILV, TGA etc. )
• Associated anomalies within each segment, or betweenthem (TAPVR, ASD, VSD, cleft mitral valve etc.)
• How the segmental combinations and connections, with orwithout the associated malformations, function
Accurate anatomical and physiological diagnosis allowsselection of therapeutic options: medical, surgical, or both.
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• Aortic coarctation• Anomalous pulmonary veins• Scimitar syndrome• Systemic venous anomalies• Branch pulmonary artery stenosis• Anomalous coronaries
• Relatively high incidence of failure of echo tocharacterize extra-cardiac vascular pathology due to lackof acoustic windows
• Failure rate increases in the post-operative setting, and inolder children, when acoustic windows diminish
• Role of MRI in these settings is well established
MRI Evaluation of extra-cardiac vasculature
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MRI Evaluation of Cardiac Morphology in CHD
• Atrial, ventricular and great arterial situs
• Segmental connections
• Status of the atrial and ventricular septum
• Cardiac valves
• Ventricular function
• Myocardium
• Echo is successful in delineating intra-cardiacpathology at all ages
• But, even in expert hands, some intra-cardiac defectsremain difficult to diagnose by echo
• Role of MRI as a trouble-shooting modality in suchsituations has not been well evaluated
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Common MR sequences used forevaluating cardiac morphology
• Black blood sequencesFast spin echo double inversion recovery
Fast spin echo with EPI readout
• Cine sequencesSteady state free precession (SSFP)
Segmented k-space gradient echo
• 3-D sequencesGadolinium enhanced 3-D MR angiography
Navigator respiratory gated isotropic 3-D SSFP
• Cine phase contrast imaging
• Myocardial perfusion and delayed enhancement
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Indications for evaluating cardiacmorphology by MRI
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Clarifying complex segmental cardiac anatomy
• MR is an excellent technique for defining themorphologic features of each atrium and ventricle
• Provides anatomical data which is easily related tothe surrounding structures of the body
• Provides reliable diagnoses in heterotaxy with asensitivity approaching 100%
• MR may be primary imaging technique in thesetting of complex intra-cardiac anatomy so as tomaximize non-invasive information prior tocatheterization
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Criss-cross ventricles, {S,D,L} TGA
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Atria - Secundum atrial septal defects
• Sensitivity of echo for diagnosing secundum ASD isclose to 100% in infancy, but drops to 85 to 90% inolder children and adults
• ASD sizing by MRI using SSFP and phase-contrastprotocols correlates well with TEE estimation
• MRI provides additional information on ASD shapesand proximity to adjacent structures
• MR guidance used recently to navigate endovascularcatheters and deliver ASD closure devices
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Secundum ASD
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Atria - Sinus venosus defect
• Superior sinus venosus defect difficult to detect byecho due to the extreme rightward and superiorposition of the defect
• Inferior type is also difficult to depict by echobecause of its infero-posterior location to the fossaovalis
• MRI has become the gold standard for depictionof sinus venosus defects
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Atria - Sinus venosus defect
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Atria – Atrial septal defects
• Successfully distinguish a common AV canal from anAV canal type of VSD or a primum ASD
• Identify atrial septal defect (ASD) or partial anomalouspulmonary venous connection in adults with right-sided chamber enlargement, hypertrophy ordysfunction of unknown etiology
• In all forms of septal defects, quantification of shuntsize (Qp:Qs ratio) by flow velocity mapping enablesdecision making regarding conservative therapy versussurgery
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Atria - Cor triatriatum
• Common pulmonary vein is usually largelyincorporated into the left atrium and forms the part ofthe left atrial posterior wall
• Membrane develops between the common pulmonaryvein and the left atrium resulting in stenosis
• Membrane lies between the entrance of the pulmonaryveins posteriorly and the foramen ovale and the leftatrial appendage anteriorly, in contrast to supra-mitralring which attaches between the foramen ovale andthe left atrial appendage posteriorly and the mitralannulus anteriorly
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Cor triatriatum Supramitral ring
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Atria - Atrial appendages
MRI has been used to demonstrate a broad rangeof pathology involving the appendages:
• Abnormal appendage symmetry in heterotaxy
• Juxtaposition of the atrial appendages inassociation with other complex malformations
• Thrombi within the appendages
• Aneurysm of the atrial appendage
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a
b
c d
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Atrioventricular connections
• Demonstrate discordant atrioventricular connectionsand crisscross atrioventricular connections
• Echocardiography is usually employed initially fordemonstrating double inlet ventricle, straddling atrio-ventricular valve, tricuspid atresia, and mitral atresia,and CMR is used to supplement this information
• CMR is superior to echo for quantifying ventricularvolumes in these abnormalities, which may becritical for surgical decisions regarding biventricularrepair versus the Fontan procedure
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Straddling and Over-riding TV
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Ventricles - VSD
• MR is highly sensitive and specific for the quantificationand detection of ventricular septal defects
• Certain types of VSD that are difficult to evaluate byecho are well suited to imaging by MR includingsupracristal defects, LV-RA shunts, and apical muscularVSDs
• Precisely depict the location of the ventricular septaldefect in relation to the great arteries in double outletventricles
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Anterior MalalignmentVSD in TOF
Apical muscular VSDin ectopia cordis
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Ventricular Morphology
• Ventricular anatomy in complex anomalies like doublechambered RV, tricuspid atresia, Shone’s syndrome,subaortic stenosis, and univentricular heart
• Differentiation of a single RV from a single LV infunctional or morphologic single ventricle
• Most accurate technique for quantifying left and rightventricular mass and volumes
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Double Chambered RV
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Infundibular outlet chamber in DILV
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Ventricles – Single vs biventricular repair
Help surgical decision making regardinguniventricular repair (Fontan), one and a halfventricle repair or biventricular repair in patientswho have two functioning ventricles, but also havefactors preventing biventricular repair:
• straddling AV valves
• Unfavorable location of the VSD
• Suboptimal ventricular morphology or function
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Valvular pathology
• High temporal resolution, spatial resolution andinteractive real-time nature of echo makes it theprimary imaging modality for defining valvemorphology
• MR velocity mapping is more accurate andreproducible means of quantifying the severity ofregurgitation
• MR helpful in morphologic depiction of tricuspidatresia, Shone’s syndrome and Ebstein's anomaly
• Precise ventricular volumetric and functionalassessment in setting of valvular pathology
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Ebstein’s Anomaly
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Tricuspid regurgitation inventricular inversion
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• Ventricular function after Fontan
• Sequential measurements of RV volumes, massand function in TOF, TGA
• Surveillance of grafts, conduits and baffles
• Early detection of complications
• Determine timing of surgical intervention
Surveillance of Corrected CHD
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Restrictive ASD after Norwood 3
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Restrictive atrialcommunication after
Norwood 3
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Conclusion• Important complementary
role to echocardiography inevaluation of cardiacmorphology and function inchildren with congenitalheart disease in the pre-operative and post-operativeperiod
• Promote awareness amongstclinicians about potential ofMRI for cardiac morphology