INDICATIONS AND USEFULNESS OF CT IN THE MANAGEMENT OF ACHD PATIENTS

Dr Haifa Abdul LatiffConsultant Pediatric Cardiologist

Institut Jantung Negara Kuala Lumpur7th TSC 2019

Content

• Real CT cases to illustrate various indications and usefulness of CT in managing ACHD patients

• Strength and limitations of CT

Utility Comments

Cardiac anatomy and function Mainly in situations when echo is suboptimal and/or MR imaging is contraindicated or limited by artifacts

Coronary artery imaging Ideal non invasive imaging modality due to high spatial resolution

Extracardiac anatomy Comprehensive evaluation including vasculature, mediastinum, lungs and airways

Presurgical/interventional Provides roadmap and measurements. Position of cardiovascular structures for redo stenotomyCalcification in vessels or conduits

3D printing Assessment of anatomyPresurgical/interventional planning, education for patients and trainees. Decrease operative/fluoroscopy time

Postsurgical/interventional Evaluation of complicationsEvaluation of prostetic valves/ventricular assist devices

Utility of CT in ACHDRadiol Clin N Am (2019) 85-111

CARDIAC ANATOMYNNAA 18YO. Presented with palpitations and reduced ET.

Diagnosed ASD. Unable to visualize RPV on echo.

Underwent PAPVD repair, fenestrated ASDOn FU. ECHO: small ASD L to R shunt

ASD

Dilated RA, RVLarge venosus ASD

RPV

RPV

NNAA pre and 3 years post PAPVD repair, fenestrated ASD

CARDIAC ANATOMY CFY 51 YO. Dilated RA RV. LPV to LA, The RLPV drains into the IVC junction. RUPV not visualised. Small PFO. CT to delineate the PV

CARDIAC ANATOMY FMK 24Y.0. History of recurrent cough. No exposure to PTB

ECHO showed Severe PHT? Cause. Mild MR. No cardiac lesion.

PDA 9mmx13mm

EXTRACARDIAC ANATOMY27 Y.O. Ref for Sinus venosus ASD with ?PAPVD. Presented with cyanosis. Chronic smoker. Only 3 pulmonary veins seen on echo. Mild PHT. Saline agitation positive.

CT to rule out PA AVMNo ASD on CT.

EXTRA-CARDIAC ANATOMYN. 39 YO man with Tetralogy of Fallot (TOF) RBTS 1984 (12 yrs) and LBTS 1988 (16yrs) in another center

2012: Reduced effort tolerance, increasing cyanosis

Echo : TOF with severe infundibular PS. Good size pulmonary valve. Satisfactory ventricular functionDifficult to delineate the PA

Cardiac Cath: could not delineate the PA well.

CTA performed. Stenosed BTS, Small PDADisconnected pulmonary arteriesGood size distal pulmonary arteries

CT: SEVERE RESIDUAL LPA STENOSIS Pre LPA stent Post LPA Stent

Underwent TOF repair and LPA augmentation several months laterStormy post op period, prolonged ventilation, tracheostomyPost op ECHO: No residual VSD, mild residual infundibular PS, could not visualize the LPA

EXTRACARDIAC ANATOMYTBT. 29Y. Dextrocardia severe MR. Post mVR and TV repair 18/6/2016.

Noted poor femoral pulses during surgery with systemic HPT. CT 4/7/2019

Collaterals into descending aorta

Pericardial and pleural effusionConsolidation of LLL Coarctation of aorta

Hypoplastic ithmus

EXTRACARDIAC ANATOMY: post repair

NAS. 30 years old. Status post repair of interrupted aortic arch 20/07/1994 Could not delineate aortic arch on echo

Double aortic arch with coarctationof descending aorta and VSD. Post VSD closure, division of the aortic arch and vascular ring repair.

Aortic conduit

EXTRACARDIAC ESC. 23YO. Left isomerism, AVSD, PA. Post R, L and central shunt. LPA is dilated.

Increasing cyanosis. To assess the shunt, PA for univentricular repair

Aneurysmal LPA Large PDA Calcified RBTS Patent LBTS to aneurysmal LPA

LPARPA

LPA

LPA

Trachea is compressed by the displaced aortic arch by the aneurysmal LPA

LPA

LPA

Thrombus in LPA

EXTRACARDIACIZ, 15 YEARS OLDPrimum ASD with cleft MV at 18 month of ageASD closure and MV repair 3 years of age. Residual moderate MR otherwise wellRecurrent fever for 1/12. Occ. headache. Enterobacter Cloacae endocarditisPlanned for surgical removal of vegetations and MVR after completed treatmentDeveloped seizure in the ward D4 admission.

CT brain: Extensive acute subarachnoid haemorrhage (SAH) with intraparenchymal component in the right frontoparietalregion

Transferred to Neuro - craniotomy, clipping of ruptured RMCA aneurysmCx: APO, AKI, Multiorgan failure and brain stem death Succumb after about 3/52 Do not take fever in patient with CHD lightly

Severe MR

Vegetations

CORONARY ARTERIES

NAM. 16YO Diagnosed CRHD with MR. MVR done. Post op FU echo ?collaterals from coronary arteries

ALCAPA

CORONARY ARTERIES

AP

LAO40 CAU30

MAI. 16Y RCA to RA fistula, tortuous small exit point. CT: Cath 2015 difficult to delineate the fistula

RCA-RA FISTULA

CORONARY ARTERIESYKO 48years. Heart failure

ECHO: severe MR.

TEE: severe MR, abnormal flow just beneath the posterior leafletDilated RCA. Differential diagnosis: RCA to LV fistula

Coronary angiogramDifficult to delineate the fistula

RCALA

FROM RIGHT POSTERIOR FROM LEFTFROM ANTERIOR

Drains just below the MV

CORONARY ARTERIESTYN. 21Y CCTGA VSD PA. BTS neonatal period. Mustard, VSD

tunnelling/closure, RV-PA conduit at GEMC. Complaint of chest pain on and off. Stress test positive. CT to assess coronary

IVC-RA-RV-PAConduit heavily calcifiedLies immediately under the sternum

Patent PV-LV Baffle

Single coronary artery, dominant LCA

LCA

CORONARY ARTERIESRP. 31 years. Chest pain

Interarterial coronary: Anomalous RCA runs between the aortic root and MPA

RCA arises from left coronary sinus

PREINTERVENTIONMAM. 14 YO. DORV, TGA, VSD and coartation of aorta. Post arterial switch, VSD closure and coarctationrepair 21/10/2005. NYHA class I. ECHO showed RVH and LVH. TR gradient 100mmHg. Mild neo AR and

AS PG 30mmHg.

LCA runs very close to the stenosed neo-MPAStenting of PA with run the risk of compressing the coronaryDecision: Surgical RVOT reconstruction

Post Le-Compte arrangement of great arteriesSevere LPA stenosisNo residual coarctation

PRE- SURGICAL INTERVENTION GG. 21YO Dextrocardia, DILV, TGA, PA. Fontan 1994. Arrhythmia. Plan

for Fontan conversion. Unable to visualize RPA on angiogram

RAA

CLASSICAL FONTAN RAA TO PA

GG. After Fontan Conversion (extracardiac Fontan)

IVC TO PA CONDUIT PPM ATRIAL LEAD

PRE CATHETER INTERVENTIONNAM. 32YO. Hemitruncus repair 1994. Severe proximal LPA stenosis

S/P RPA stenting 2018. ECHO unable to visualize RPA and LPA.

2017Measurement of length and size of LPATo guides the stent size

Assess LPA growth, stent patency and complicationStent fracture

POST INTERVENTION2019

STRENGTH AND LIMITATIONS OF CTSTRENGTH :

– Fast– Excellent spatial and temporal resolution – Wide field of view without acoustic window restrictions– Easily available

LIMITATIONS: – ionizing radiation – contrast related complications (nephrotoxicity, allergy) – Static image, limited dynamic information (ECG gated) – poor myocardial characterization – artifacts (dense contrast, movement)

Optimization of image• Proper timing of contrast to ensure good contrast enhancement

of the structure of interest.

• Communicate with CT imager of cardiac anatomy (intracardiacshunts), previous surgery or intervention and information required from the study

• Decide on study protocol (ECG or non ECG gated) and scanning plan (timing of acquisition, volume and rate of injection)

• Good contrast enhancement is important for a good quality 3D printing

SUMMARY• CT plays an important roles in the management of ACHD

patients

• Provide precise information on cardiac and extracardiaclesions, guides on the surgical/catheter interventions, assess the result of treatment

• Understanding the CT strengths and limitations, good communication between the cardiologist and CT imager on the cardiac lesions and information required are important factors to ensure success of the study

Thank you