ElieMousseaux

GillesSoulatFrancescaPitoccoEtienneCharpentier

RoleofCTandMRinFallotdisease

Conflict of Interest from 2014 to 2018

ElieMousseaux

Nolinkorconflictwiththefollowingpresentation

Background

Chiuetal.CircCardiovascQualOutcomes2012

Background

• Predictorsofoutcome:•  RVhypertrophy•  RVdysfunction•  LVdysfunction•  Atrialtachyarrhythmia

Valenteetal.Heart2014

•  ESC2010guidelinesClassIIa/LevelCPVRshouldbeconsideredinasymptomaticpatientswithseverePRwhenatleastoneofthecriteriaispresent:

•  Decreaseinobjectiveexercise•  ProgressiveRVdilatation•  ProgressiveRVdysfunction•  Progressivetricuspidregurgitation•  Sustainedatrial/ventriculararrhythmias

Role of CMR

• Rolevariesaccordingageandclinicalcircumstance•  Firstdecade:TTEisalmostsufficient.CMRisnotrecommendedroutinely•  After,CMRisrecommendedforRVsize,functionandpulmonaryregurgitation.

•  Echographywindowsmorerestricted•  Adverseclinicaloutcomeincreases•  NosedationforCMRinadolescentsandadults

Valenteetal.JASE2014.

MR Scanning/Reports elements

RVandLVvolumes,mass,SVandEF

Wallmotionabnormalites

AnatomyofRVOT,PA,aorta

QuantificationofPR,TR,CardiacoutputanQP/QS

Viability

RV size and function

Gevaetal.JCMR2011

Background

Oosterhofetal.Circulation2007

RV size and function

Gevaetal.JCMR2011

LV function

• Impairedin20%ofFallotdisease.Strongprognosticfactor.

Gevaetal.JACC2004

Anatomy of RVOT

3DSSFPSequence:ECGgated,andMPRpossible.2DSSFP:usefulforwallmotionassessment3DMRA:nonsynchronized:motionartefact.TSE:lesssensitivetometallicartifact.Importantelementforplanningpercutaneousimplantation

RVOT

Anatomy of PA

•  Magneticresonanceangiography•  Evaluationofbranchstenosis

Quantification of PR

Anatomy of aorta

• Rightaorticarchin25%ofpatients

Cardiac output and QP/QS

QP=4.03ml;QS=4.12ml

Late Gadolinium Enhancement

• ProposedrecommendationforLGEevaluation:•  FirstCMRexamination•  >3yearssincelastLGEevaluation•  Deteriorationinclinicalstatus• Worseregionalorglobalventricularfunction

Occursin•  Locationofpriorsurgery•  Ubiquitusinsuperiorandinferiorjunction

Relationwithmortalityremainsunclear

Valenteetal.JASE2014.

Other issues in CMR

• Coronaryanatomy

•  ImportantbeforepercutaneousPVimplantation

•  CTincaseofsuspectedabnormaloriginand/ortract

•  Relationshipwithsternum

Ao PA

Advantages of 4D vs 1D

VMaxFonctiondesonorientationFonctiondudébitsousjacent

JMRI1015

Tetralogy of Fallot with 4D f

RF = 45% No shunt Qp/Qs = 1

CMR limits / Role of CT

• LimitsofCMR•  Cost(comparisonwithTTE)•  Noportability•  Availability•  Artifactforimplantswithstainlesssteel•  ContraindicationforPManddefibrillator

RoleofCT

Excellentspatialresolution:coronaryarteryanddistalpulmonarybranches

CT

•  LimitsofCT•  Ionisingradiation•  Lowertemporalresolution•  Nonhemodynamicinformationonflowrateandvelocity•  Riskofcontrastinpatientwithimpairedrenalfunction.

•  Giventheyoungageofthispopulation,MDCTshouldbereservedinpatientswithabsolutecontraindicationtoCMR

•  SpecificTASK=endocarditisafterPulmonaryValveReplacement

Endocarditis in Fallot Disease and CT

Take home messages

• InFallotdisease,CMRisthereferencestandardforquantificationof

•  RVsize•  RVfunction•  Pulmonaryregurgitation

• OtherinformationprovidedbyCMR:LVfunction,myocardialfibrosis,Anatomyofpulmonarytreeandaorta.

• CTshouldbereservedinpatientwithCItoCMR,andisnotablyusefulforstentvisualizationandcoronaryanatomy