Cardiac CTA - Congenital Heart Diseases

Marilyn J. Siegel, MDMallinckrodt Institute of Radiology

Washington University Medical CenterSt. Louis, Mo

Visiting Scientist, AFIP, Washington, DC

Advances in Cardiac ImagingCTA of Congenital Heart Disease

Conflict of Interests

• GE Healthcare-speaker• Siemens-speaker

Copyright Society for Pediatric Radiology, 2008. All Rights Reserved.

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Objectives

• Discuss technique for cardiac CT in children

• Describe practical applications for MDCT in congenital heart disease

Why Do Cardiac CT?

• CHD occurs in about 1% of neonates• With advances in surgery, more than

85% expected to reach adulthood• Many or most need lifelong care• YOU WILL SEE THESE DISEASES


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Why Do CT for CHD?

•Even if you don’t plan to do cardiac CT, you need to recognize these diseases because they will be discovered incidentally

Dedicated CT Protocol (CHD)

• Technique similar to PE study• Detector collimation: < 1mm• Pitch 1-1.5• Recons-routine viewing: 3 x 3• Recons-3D: 2 x 1 mm• Image order: cranial-caudal or reverse• No ECG gating


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Contrast Administration

• 1.5-2.0 mL/kg (max 125 mL)

• Nonionic• Flow rate: 2.0-3.0

mL/sec • Bolus tracking

– 100-120 HU– ROI over area of

interest

Positioning the ROI

• Aorta and surgical shunts– Aorta

• Pulmonary artery– Main PA or branches

• Pulmonary veins: LA


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CHD: Viewing the Images

LA

DON’T IGNORE AXIAL DATA Often suffice for intracardiac lesions

valves, atria and ventricles

RARVOT

RV

LV

Volume Rendering-3DMultiplanar-2D

Post-Processing

LV

Use MPR and 3D to view great vessels, outflow tract and ventricular wall


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Indications: Pediatric Cardiac CT

• Usually performed to study extra-cardiac vessels and post-operative anatomy

• No role in defining normal anatomy• No role in assessing function• Not a screening tool

Top Congenital Heart Diseases

SHUNTS

VSDASDPDA

CYANOTIC

Tet of FallotD-TGVTricuspid atresiaTruncusTAPVR

OBSTRUCTIVE

CoarctationAortic stenosisPulmonic stenosis


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Obstructive Lesions: Coarctation

• Juxtaductal stenosis of proximal descending aorta

• Short segment (post-ductal)– Normal diameter arch– Collaterals common

• Long segment (pre-ductal)– Hypoplastic arch

Multimedia LibraryChildren's Hospital Boston

Short Segment Coarctation


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Short Segment CoarctationNeed reconstructionsSagittal/oblique views>>>axial

Spectrum of Images:Focal (Post-Ductal) Coarctation

Collaterals, dilated ascending aorta


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Structures Coursing Obliquely:You need MPR & 3D Images

• Axial images–Sensitivity 90%

• MPR and 3D reconstructions essential–Sensitivity 100% – add information in 10% of cases

»short focal lesions»vessels that course obliquely

Lee, Siegel AJR 182:777-784

Long Segment Coarctation

• Hypoplastic arch• Collaterals uncommon

Neonate with CHF


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Short Segment Coarctation

• Collaterals via intercostal & mammary arteries

• 3rd-8th ribs

Coarctation RepairResection & end-to-end anastomosisStents, angioplasty, patch aortoplasty

subclavian


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Post-repair Complications (5-30%)

Restenosis Pseudoaneursym

Aortic Stenosis• Bicuspid valve in 95% of cases• Prone to degeneration and calcification

–Leads to stenosis or regurgitation• Isolated or associated with coarctation

library.med.utah.edu/WebPath/


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Aortic Stenosis

Bicuspid valve

Normal

Pulmonic Valve Stenosis90% commissural fusion10% dysplastic valve

M

L


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A Little Bit More Difficult: Simple Cardiac Shunts

• Atrial septal• Ventricular septal• Patent ductus

Easily seen by echocardiography, but patients may be referred to CT for other reasons

Atrial Septal Defects

• Sinus venosus (10%)– Level of SVC– associated with PAPVR

• Secundum (60%)– Level of fossa ovalis

• Primum (30%)– Lower atrial septum– Part of AV canal defect

primum


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Associated with anomalous RUL venous return

Sinus Venosus

Upper septal defect

med.yale.edu

Secundum ASD

RA

Mid septal defect


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Primum ASD

Lower septal defect

Virtual Children’s Hospital

RA

LA

ASD: Overview

VSD

ASD


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•Most common CHD•Locations

–Peri-aortic (80%)–(perimembranous)

–Intramuscular–Subpulmonic–Right ventricular inlet–(part of AV canal)

Ventricular Septal Defects

med.yale.edu

inlet

Ventricular Septal Defects

Membranous Muscular


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Multiple VSDs: Swiss cheese

Complicated CHD: CT to evaluate BT shunt

Patent Ductus ArteriosusDescending Aorta to LT PA

Case radiograph

med.yale.edu

MPR/3D images >> axial for oblique vessels

P


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Patent Ductus Arteriosus

Adolescent with a murmur

P

A

3D

Complex Congenital Heart Disease

• Indications for CTA:–Evaluate surgical shunt patency–Assess intracardiac anatomy–Evaluate size/confluence of PAs–Identify collateral vessels

• Limited role in diagnosis of untreated CHD–Know the clinical question–Know the anatomy


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Tetralogy of Fallot Clues: 4 Findings

• The Tetrad–Subaortic VSD–Infundibular pulmonic stenosis–Overriding aorta–Right ventricular hypertrophy

Tetralogy of Fallot

VSD

RVH

PS

Ao


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Surgical Repair TOF

Blalock Taussig shunt

Repaired Tetralogy of Fallot

PA

PA


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Transposition of Great VesselsAtrial Switch

www.kumc.edu www.rjmatthewsmd.com

D-TGV

S

RV

Pulmonary venous limb

Systemic limb


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Complications: Baffle Stenosis & Leak

Other Clue to DiagnosisD-Transposition Great Vessels

Aorta anterior/right of PA

RV LV

A PA


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Arterial Switch: Jatene Procedure• Aorta reconnected to LV; PA to RV

Aorta to left of PA

PA

PA

A

Levo (L)-TGV

• LV & RV transposed • Aorta anterior/left of PA

RARALVLV

LALARVRVRARA LVLV PAPA

LALA RVRV AoAo


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AAPP

AAPP

Tran

spos

ition

Tran

spos

ition

NormalNormal

AAPP

DD--TGATGALL--TGATGA

Great Vessels

Tricuspid AtresiaTricuspid Atresia

• The Clues:• Fatty bar between RA/RV• Hypoplastic RV• Large RA • Treatment

– Glenn shunt– Fontan Procedure

RA

RV

RALA


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Univentricular HeartSingle Functional Chamber

Palliative treatment

FontanGlenn

SVC

PA

Modified Fontan

www.med.yale.edu www.kinder-kardiologe www.childrenshospital.org

RA PA

IVC


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Total Cavopulmonary Shunt

• IVC not opacified since scan acquired during arterial phase

• Delayed scanning opacified shunt and inferior vena cava

SVC

Shunt

Type 1Truncus Arteriosus

Post repair

A PA

Neonate with cyanosis


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Total Anomalous Pulmonary Return

Vertical vein


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• This is a 2-month-old girl who has undergone palliative surgery for cyanotic heart disease. In this 3D volume-rendered image, which is the MOST likely surgical procedure indicated by the arrow?

A. Glenn shuntB. Blalock-Taussig shuntC. Potts shunt D. Waterston shuntE. Fontan procedure

BT shunt Glenn Fontan

WaterstonAsc Ao-PA

PottDesc Ao-PA


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• Increased incidence of CHD• More complicated cases• Diagnosis depends on knowledge of

CT and clinical findings


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Cardiac CTA - Congenital Heart Diseases

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