ORIGINAL RESEARCH
MRI o Guided Righ and Le Hea
Ca diac Ca he e iza ion: A P ospec i e
S udy in Congeni al Hea Disease
Ma i Nie es Velasco Fo e, MRCPh,
1,2,3
*Sébas ien Roujol, PhD,
1
B am Ruijsink, PhD,
1,2
Is ael Val e de, MD,
1,2,3
Phuoc Duong, MRCPh,
1,2
Nick By ne, MSc,
1,4
Sascha K uege , PhD,
5
S e en Weiss, PhD,
5
Youse A a , MD,
6
Su end ana h R. Vee am Reddy, MD,
6
Tobias Schae e , PhD,
1
Ta ique Hussain, PhD,
1,6
Reza Raza i, MD,
1,2
and
Kube an Pushpa ajah, MD
1,2
Backg ound: Imp o emen s in ou comes o pa ien s wi h congeni al hea disease (CHD) ha e inc eased he need o
diagnos ic and in e en ional p ocedu es. Cumula i e adia ion isk is a g owing conce n. MRI-guided in e en ions a e a
p omising ionizing adia ion- ee, al e na i e app oach.
Pu pose: To assess he easibili y o MRI-guided ca he e iza ion in young pa ien s wi h CHD using ad anced isualiza ion
passi e acking echniques.
S udy Type: P ospec i e.
Popula ion: A o al o 30 pa ien s wi h CHD e e ed o MRI-guided ca he e iza ion and pulmona y ascula esis ance
analysis (median age/weigh : 4 yea s / 15 kg).
Field S eng h/Sequence: 1.5T; pa ially sa u a ed (pSAT) eal- ime single-sho balanced s eady-s a e ee-p ecession
(bSSFP) sequence.
Assessmen : Images we e isualized by a single iewe on he scanne console (in e ac i e mode) o using a comme cially
a ailable ad anced isualiza ion pla o m (iSui e, Philips). Image quali y o ana omy and ca he e isualiza ion was e alu-
a ed by h ee ca diologis s wi h >5 yea s’expe ience in MRI-ca he e iza ion using a 1–5 scale (1, poo , 5, excellen ). Ca he-
e balloon signal- o-noise a io (SNR), blood and myoca dium SNR, ca he e balloon/blood con as - o-noise a io (CNR),
balloon/myoca dium CNR, and blood/myoca dium CNR we e measu ed. P ocedu e findings, easibili y, and ad e se
e en s we e eco ded. A ac ion o ime in which he ca he e was isible was compa ed be ween iSui e and he
in e ac i e mode.
S a is ical Tes s: T- es o nume ical a iables. Wilcoxon signed ank es o ca ego ical a iables.
Resul s: Nine pa ien s had igh hea ca he e iza ion, 11 had bo h le and igh hea ca he e iza ion, and 10 had single
en icle ci cula ion. Nine pa ien s unde wen solely MRI-guided ca he e iza ion. The mean sco e o ana omical isualiza-
ion and con as be ween balloon ip and so issue was 3.9 0.9 and 4.5 0.7, espec i ely. iSui e p o ided a signifi-
can imp o emen in he ime du ing which he balloon was isible in ela ion o in e ac i e imaging mode (66 17%
s. 46 14%, P< 0.05).
View his a icle online a wileyonlinelib a y.com. DOI: 10.1002/jm i.27426
Recei ed Aug 17, 2020, Accep ed o publica ion Oc 19, 2020.
*Add ess ep in eques s o: M.N.V.F., 3 d Floo Lambe h Wing S Thomas’Hospi al Wes mins e B idge Road, London SE1 7EH, UK.
E-mail: mnie es. [email protected]
Con ac g an sponso : Welcome Enginee ing and Physical Sciences Resea ch Council (EPSRC) Cen e o Medical Enginee ing a King’s College London;
Con ac g an numbe : WT 203148/Z/16/Z; Con ac g an sponso : EPSRC; Con ac g an numbe : EP/R010935/1; Con ac g an sponso : B i ish Hea Foun-
da ion (BHF); Con ac g an numbe : PG/19/11/34243; Con ac g an sponso : Na ional Ins i u e o Heal h Resea ch (NIHR) Biomedical Resea ch Cen e awa d
o Guy’s and S Thomas’Na ional Heal h Se ice (NHS) Founda ion T us in pa ne ship wi h King’s College London; Con ac g an sponso : NIHR Heal hca e
Technology Co-ope a i e o Ca dio ascula Disease a Guy’s and S Thomas’NHS Founda ion T us .
F om he
1
School o Biomedical Enginee ing and Imaging Sciences, King’s College London, London, UK;
2
Depa men o Congeni al Hea Disease, E elina
London Child en’s Hospi al, Guy’s and S Thomas’NHS Founda ion T us , London, UK;
3
Ca dio ascula Pa hology Uni , Ins i u e o Biomedicine o Se ille, IBIS,
Vi gen del Rocio Uni e si y Hospi al/CSIC/Uni e si y o Se ille, Se ille, Spain;
4
Depa men o Medical Physics, Guy’s and S . Thomas’NHS Founda ion T us ,
London, UK;
5
Philips Resea ch Eu ope, Hambu g, Ge many; and
6
Depa men o Pedia ics, UT Sou hwes e n Medical Cen e , Dallas, Texas, USA
Addi ional suppo ing in o ma ion may be ound in he online e sion o his a icle
This is an open access a icle unde he e ms o he C ea i e Commons A ibu ion License, which pe mi s use, dis ibu ion and ep oduc ion in any medium,
p o ided he o iginal wo k is p ope ly ci ed.
© 2020 The Au ho s. Jou nal o Magne ic Resonance Imaging published by Wiley Pe iodicals LLC.
on behal o In e na ional Socie y o Magne ic Resonance in Medicine.
1446
Da a Conclusion: MRI-guided ca he e iza ions we e ca ied ou sa ely and is easible in child en and adul s wi h CHD. The
pSAT sequence o e ed obus and simul aneous high con as isualiza ion o he ca he e and ca diac ana omy.
Le el o E idence: 2
Technical E ficacy S age: 1
J. MAGN. RESON. IMAGING 2021;53:1446–1457.
CONGENITAL HEART DISEASE (CHD) is he mos
equen ly occu ing congeni al diso de in newbo ns
and he mos equen cause o in an dea h om bi h
de ec s.
1
Imp o emen s in diagnosis and ea men ha e led
o a la ge numbe o pa ien s eaching adul hood, wi h an
inc ease o 55% in he p e alence o adul s li ing wi h se e e
ypes o CHD in he las decades.
2
This ise in he popula-
ion wi h CHD has made he seconda y e ec s om cu en
adiog aphic based echniques become mo e e iden ,
3,4
A
ecen s udy has shown a significan ele a ion in bioma ke s
o ch omosomal damage bo h o diagnos ic and he apeu ic
ca diac ca he e iza ion p ocedu es, s a ing ha no sa e dose
exis s o adia ion in child en.
5
Magne ic esonance imaging (MRI)-guided ca he e iza-
ion o e s an al e na i e o x- ay-guided ca diac p ocedu es,
a oiding adia ion and p o iding be e so - issue isualiza-
ion. In humans, passi e acking echniques ha e been used
o diagnos ic pu poses in an inc easing numbe o s udies,
wi h isola ed se ies o success ul in e en ions.
6-8
Di e en
isualiza ion echniques in ol ing passi e acking ha e been
a emp ed using balloon wedge ca he e s. A ca bon dioxide
(CO
2
)-filled balloon can be isualized as a signal oid.
6
Con as -based app oaches use dilu ed gadolinium ins ead,
which may be isualized by applying sa u a ion p epulses
in e mi en ly,
9
a black-blood p epa a ion using flow-sensi i e
g adien s,
10
o wi h pa ial sa u a ion (pSAT) p epulses.
11
The la e op ion o e s simul aneous isualiza ion o he bal-
loon, ca diac ana omy, and blood pool.
Ca diac p ocedu es unde MRI guidance in humans
ha e been ca ied ou using a single 2D iewe on he scanne
console
6-8
( e e ed o as in e ac i e mode in his a icle) o
by u ilizing an ad anced isualiza ion pla o m in a sepa a e
wo ks a ion enabling eal- ime isualiza ion o 3D da a and
mul iplane images, such as iSui e (Philips, Bes , he Ne he -
lands) o In e ac i e F on End (Siemens Co po a e Resea ch,
P ince on, NJ).
12,13
The second op ion has been used o
clinical pu poses in elec ophysiology (EP) s udies and igh
hea ca he e iza ion o pulmona y ascula esis ance analy-
sis in adul and pedia ic pa ien s.
12-17
The pu pose o his s udy was o e alua e he possibili y
o pe o ming MRI-guided ca he e iza ion and o assess he
quali y o isualiza ion using a p e iously desc ibed pSAT
sequence in an in e ac i e mode o embedded in iSui e o
op imize isualiza ion o igh and/o le hea ca he e iza-
ion in child en (including in an s) and young adul s
wi h CHD.
Ma e ials and Me hods
Thi y- ou consecu i e pa ien s wi h CHD e e ed o pulmona y
ascula esis ance (PVR) analysis we e conside ed o he s udy. The
p o ocol was app o ed by he Ins i u ional Re iew Boa d. W i en
in o med consen was ob ained om all pa icipan s o hei legal
ep esen a i es.
In Vi o Valida ion
The en i e se up was ini ially es ed, op imized, and alida ed using
a 3D-p in ed hea phan om. The no mal igh hea o a 2-yea -old
pa ien was p in ed o his pu pose.
The segmen a ion and s anda d essella ion language (STL)
file p epa a ion we e pe o med manually using Mimics so wa e
( . 18.0, Ma e ialise, Leu en, Belgium) and 3-Ma ic Medical
( . 10.0, Ma e ialise). The model was p in ed using polyje echnol-
ogy in Tango Plus FullCu e930 ma e ial in a hollow ashion o allow
he simula ion o he in e en ion. The in e io ena ca a (IVC) and
supe io ena ca a (SVC) we e a ificially elonga ed in o de o acili-
a e he phan om expe imen s. The 3D model was hen a ached o
a wa e -filled plas ic box using six F ench in oduce s connec ed a
each end.
Visualiza ion and na iga ion we e es ed using a p e iously
desc ibed pSAT sequence
11
in in e ac i e mode o embedded in
iSui e. A 5F balloon wedge ca he e was used, infla ed wi h 1–2mL
o a 1% dilu ion o gadolinium (Do a em) a he balloon ip o all
expe imen s.
Each ope a o pe o med he p ocedu e h ee imes. Ca he e i-
za ion was pe o med ollowing he same s a egy and ou e as in
clinical cases. Fi s , a 3D bSSFP was acqui ed and selec ed imaging
planes we e s o ed when iSui e was u ilized. The ca he e was hen
na iga ed om he IVC o he igh a ium, igh en icle, main
pulmona y a e y (PA), and PA b anches (Fig. 1). A 5-channel ca -
diac a ay ecei e coil was used o he expe imen s.
Real-Time MRI-Guided Ca diac Ca he e iza ion
Imaging was pe o med on a Philips XMR se up (Achie a o
Ingenia, Philips, Bes , Ne he lands). This consis s o a 1.5T MRI-
scanne and a BV Pulse a o Allu a Cla i y o Ingenia (Philips) ca -
diac X-Ray uni . All s udies we e conduc ed unde gene al anes hesia
based on clinical need. An app op ia e size balloon wedge ca he e
(A ow In l., Reading, PA) and ecei e coil we e used depending on
he weigh o he pa ien (Table 1).
Access o he igh o le emo al ein and a e y was gained
in he x- ay pa o he XMR sui e. Once access was gained, he
pa ien was ans e ed o he scanne and an app op ia e size ca he-
e was inse ed. The balloon a he ca he e ip was filled in wi h a
dilu ion o 1% gadolinium (Do a em, Gue be , F ance) mixed wi h
a physiological 0.9% sodium chlo ide solu ion. Balloons we e ini-
ially infla ed o a maximal olume as ecommended by he manu-
ac u e . Howe e , he olume injec ed in he balloon- ip was
May 2021 1447
Velasco Fo e e al.: iCMR in Congeni al Hea Disease
adap ed o he size o he na iga ed s uc u es. This was pa icula ly
necessa y when app oaching he PA b anches, whe e he size o he
essels educed in calibe in ela ion o he diame e o he eeding
essel, and whe e s enosis is a common finding in pa ien s
wi h CHD.
The iSui e pla o m consis s o a PC loca ed nex o he scanne
console whe e he so wa e is ins alled, wo mi o ed sc eens (one nex
o he iSui e PC in he scanne console oom and one in he scanne
oom), and a se o oo pedals. The scanne console and he iSui e
PC we e elec onically connec ed and images sen au oma ically in
eal- ime. Fo each case, a e su ey and localize s scans, a 3D bal-
anced s eady-s a e ee-p ecession (bSSFP) sequence was acqui ed a
he beginning o he s udy. Using he 3D bSSFP images impo ed
in o iSui e, pa ien -specific imaging planes we e defined o he ollow-
ing ana omical iews: bica al (mul iplana e o ma showing he SVC
and IVC), 4-chambe , igh en icula ou flow ac (RVOT), igh
3-chambe (R3ch), pulmona y a e y (PA) bi u ca ion, igh and le
pulmona y a e ies (RPA and LPA, espec i ely) o igh hea ca he-
e iza ion. Le en icula ou flow ac (LVOT), le 3-chambe
(L3ch), and ao ic a ch ana omies we e also s o ed o pa ien s needing
le hea in es iga ions. P essu es we e measu ed and eco ded ac oss
all ca diac chambe s ca he e ized. In h ee cases an MRI condi ional
wi e (EP flex Feinwe k echnik, Ge many, 0.03500 diame e and
180 cm leng h) was used.
The iSui e sc een in he scanne oom was used o he ope a-
o ’s guidance. Real- ime imaging was con olled by he oo pedals.
These could be used o swi ch be ween a s anda d single-plane
acquisi ion and dynamic in e lea ed acquisi ions o wo o h ee
o hogonal imaging planes ha could be displayed simul aneously,
and o s a o s op imaging. The ope a o was able o na iga e back-
wa ds and o wa ds in he same plane o ien a ion by p essing he
pedals, each mo emen ad anced 80% o he p e iously defined slice
hickness o he sequence. Fo ca he e iza ion guidance, a p e iously
desc ibed pSAT sequence ( epe i ion ime [TR] / echo ime
[TE] = 2.65 msec/1.3 msec, flip angle = 60,field o iew
[FOV] = 350 ×300 mm
2
, oxel size = 2.2 ×2.5 mm
2
, slice hick-
ness = 10 mm, bandwid h = 1250 Hz/pixel, SENSE ac o = 2, pa -
ial k-space acquisi ion in he phase-encoding di ec ion = 65%,
numbe o phase encoding lines = 40, acquisi ion ime = 106 msec)
was used.
11
The pSAT angle o ob ain pa ial sa u a ion was op i-
mized o isualiza ion in each case. The slice hickness was adap ed
depending on he pa ien ’s weigh and he size o he s uc u es ha
needed o be ca he e ized (Table 1).
Image Quali y Assessmen and Feasibili y o MRI
Ca he e iza ion
Image quali y o ana omy and ca he e isualiza ion was e ospec-
i ely e alua ed by h ee ca diologis s (I.V., T.H., K.P.) wi h 11, 12,
and 10 yea s o expe ience in c oss-sec ional imaging and MRI ca h-
e e iza ion, espec i ely, using a 1–5 scale (1, poo , 5, excellen ).
11
Ca he e balloon signal- o-noise a io (SNR), blood SNR,
myoca dium SNR, ca he e balloon/blood con as - o-noise a io
(CNR), ca he e balloon/myoca dium CNR, and blood/myoca dium
CNR we e measu ed o each case, as p e iously desc ibed.
11
Demog aphic da a, diagnosis, mean hea a e and end- idal
CO
2
(e CO
2
) du ing he p ocedu e, adia ion dose and ime, pul-
mona y ascula esis ance a es and unde inhaled asodila o s,
and ad e se e en s we e eco ded. As pe ins i u ional p o ocol, base-
line PVR was assessed unde 30% ac ion o inspi ed oxygen (FiO
2
)
and epea ed wi h inhaled pulmona y asodila o s and 100% ac-
ion o inspi ed oxygen when indica ed.
Fo each pa ien , we e alua ed he easibili y o MRI-guided ca h-
e e iza ion and ac ion o ime du ing MRI ca he e iza ion in which he
ca he e was isible in a leas one plane o space. Slice hickness and he
pSAT angle used du ing ca he e iza ion we e eco ded. All medical pe -
sonnel in ol ed in MRI-guided in e en ions a ou ins i u ions we e
ained in MRI sa e y be o e pa icipa ion in clinical scena ios.
S a is ical Analysis
S a is ical analysis was pe o med wi h IBM SPSS . 20.0 (A monk,
NY). Nume ical alues a e p esen ed as mean s anda d de ia ion
(SD) unless s a ed o he wise. The ac ion o ime in which he ca he e
was isible was compa ed be ween iSui e and in e ac i e mode. A - es
was used o es o di e ences be ween he wo guidance app oaches in
e ms o ac ion o ime in which he ca he e was isible. Fo ca ego i-
cal a iables (sco es), a Wilcoxon signed ank es was pe o med o e al-
ua e s a is ical significance. Ca ego ical a iables a e p esen ed as median
and ange unless s a ed o he wise. P< 0.05 was conside ed significan .
Resul s
Demog aphic Fea u es and P ocedu e Findings
F om he 34 consecu i e pa ien s ini ially e e ed o PVR
s udy, 30 pa ien s we e finally ec ui ed ( wo pa ien s
declined en olmen , one pa ien had a pacemake implan ed,
and one pa ien was an adul wi hou capaci y o consen ).
FIGURE 1: Visualiza ion o he balloon wedge ca he e in a 3D p in ed hea . Tip o he ca he e a he igh a ium (le ), o igin o
he le pulmona y a e y (cen e ) and in he igh pulmona y a e y ( igh ).
1448 Volume 53, No. 5
Jou nal o Magne ic Resonance Imaging
TABLE 1. Diagnosis, P e ious P ocedu es, Weigh , Slice Thickness, pSAT Angle, Size o Balloon Wedge Ca he e , Coil, and Scanning Me hod Used o Each
Pa ien
Pa ien Diagnosis
P e ious ca diac
p ocedu es
Weigh
(kg)
Slice
hickness/
pSAT flip
angle Hea s uc u es ca he e ized
Size o balloon wedge
ca he e (F ench)/Use o
MRI compa ible wi e Coil
Scanning
me hod
1 Comple e AVSD Nil 49 10 mm/30IVC, RA, RV, MPA, LPA,
LCPW
6/No Ca diac
coil
In e ac i e
2
a
Allagile’s synd ome. Bila e al PAs s enosis Nil 7.5 10 mm/30IVC, RA, RV, MPA, LPA,
RPA, RPCW, DAo, AAo,
LV
4/No Ca diac
coil
iSui e
3 DORV, malposi ion o he g ea a e ies
William’s Synd ome
As hma
Uppe ai way obs uc ion (pa ial ocal palsy)
•Modified BT shun
•VSD closu e, ASO
(Lecomp e), excision o
subpulmona y s enosis
98 8 mm/50IVC, RA, RV, RPA, MPA,
DAo, AAo, LV
6/No Ca diac
coil
iSui e
4
a
Allagile, PAs s enosis Nil 12.2 5 mm/30IVC, RA, RV, MPA, LPA,
RPA, RPCW, DAo, AAo,
LV
4/No Ca diac
coil
iSui e
5 Le a ial isome ism
In e up ed IVC wi h bila e al azygos con inua ion
PAPVD (RPV o igh sided a ium), small ASD,
pe imemb anous VSD
Pulmona y hype ension
•Comple e su gical epai 14 7 mm/30IVC, RA, RV, MPA, LPA,
RPA, RPCW, DAo, AAo,
LV
4/No Ca diac
coil
In e ac i e
6 TGA, AP window Nil 11 7 mm/30IVC, RA, RV, MPA, LPA,
LPCW, Ao a
4 ( ) & 5 (a)/No Ca diac
coil
iSui e
7 AVSD Nil 6.5 7 mm/40IVC, LA, RA, RV, LV, MPA,
LPA, RPA, RCPW
4/No Flex M iSui e
8 TOF •Balloon dila a ion o
pulmona y al e
•Su gical epai o TOF
& LPA econs uc ion
•Balloon dila a ion o
igh uppe , RUPA,
RMPA &RLPA
•Balloon dila a ion o
LPA & s en inse ion
33 10 mm/30-
45
IVC, RA, RV, MPA, RPA,
(LPA a emp ed bu
obs uc ed), RCPW
6/No Ca diac
coil
iSui e
9 HLHS Single en icle –s/p
Fon an
45 8 mm/40IVC, LL, SVC, RPA, LPA,
LPCW, RA, LA, RV
6/No Ca diac
coil
iSui e
10 TAPVD, se e e RPV s enosis •Su gical epai o
TAPVD
•Balloon dila a ion o
RUPV
25 7 mm/40IVC, RA, RV, LPA, RPA,
RPCW, LPCW, DAo, AAo,
LV
5 ( ) & 4 (a)/No Ca diac
coil
iSui e
May 2021 1449
Velasco Fo e e al.: iCMR in Congeni al Hea Disease
TABLE 1. Con inued
Pa ien Diagnosis
P e ious ca diac
p ocedu es
Weigh
(kg)
Slice
hickness/
pSAT flip
angle Hea s uc u es ca he e ized
Size o balloon wedge
ca he e (F ench)/Use o
MRI compa ible wi e Coil
Scanning
me hod
11 Secundum ASD, Pe imemb anous VSD, T21 Nil 6 7 mm/40IVC, RA, LA, RV, MPA, LPA,
RPA, LPCW,
4/No Flex L iSui e
12 PAPVD (LU&LMPV o innomina e ein),
pe imb anous VSD
Nil 5 7 mm/40IVC, RA, RV, LPA, RPA,
LPCW, RPCW.
DAo, AAo, LV
4/No Flex L iSui e
13 AV disco dance, DORV •Single en icle –s/p
Fon an
60 8 mm/30IVC, LL, SVC, RA, LA, RV,
RPA, LPA, LPCW
6/No Ca diac
coil
iSui e
14 PAPVD (RPV o RA), secundum ASD •Coil embolisa ion o
MAPCAs
5.5 N/A IVC, RA, RV, MPA, LPA
(RPA a emp ed bu
obs uc ed), LA, LV, DAo,
Asc Ao
4/No Ca diac
coil
N/A
15 HLHS Single en icle –s/p
Fon an
20 7 mm/30IVC, LL, SVC, RPA, LPA,
LPCW, RA, LA, RV
6/No Ca diac
coil
iSui e
16 C iss-c oss hea , ASD, se e e subpulmona y and
pulmona y al e s enosis
Nil 19 N/A IVC, RA, RV, MPA, RPA,
LPA, RPCW
5/No Ca diac
coil
N/A
17 Disco dan AV connec ions, conco dan VA
connec ions
•Single en icle –s/p
Glenn
11.5 8 mm/30IVC, RA, LV, SVC, RPA,
LPA, LPCW
4/No To so
coil
In e ac i e
18 HLHS •Single en icle –s/p
Fon an
21.3 8 mm/40IVC, LL, SVC, RPA, LPA,
LPCW, RA, LA, RV
6/No To so
coil
In e ac i e
19 HLHS •Single en icle –s/p
Glenn
18 8 mm/40IVC, RA, RV, SVC, RPA,
LPA, LPCW
5/No To so
coil
In e ac i e
20 Ao ic Coa c a ion, mode a e sized VSD, congeni al
le diaph agma ic he nia and le lung hypoplasia,
13 ch omosome dele ion, scoliosis
•Ao ic coa c a ion epai 7 10 mm/40IVC, RA, RV, MPA, RPA,
RPCW, LPA, LPCW, LV,
AAo, DAo
4/Yes Ca diac
coil
iSui e
21 Common a ium, iny muscula VSD •ASD closu e 34 10 mm/40IVC, RA, RV, MPA, RPA,
LPA, LPWC
6/Yes Ca diac
coil
iSui e
22 HLHS, Le pulmona y ein s enosis •Single en icle –s/p
HemiFon an
•LPV s en
13 N/A SVC, LPA, LPCW, RPA,
RPCW
4/No Ca diac
coil
N/A
23 Pe imemb anous en icula sep al de ec Nil 15 10 and
5 mm/
40
IVC, RA, RV, MPA, LPA,
RPA, RPCW, LV, AAo,
DAo
5/No Ca diac
coil
iSui e
24 HLHS •Single en icle –s/p
Fon an
•LPA s en
24 N/A IVC, LL, LPA, RPA, RPCW,
RA, RV, AAo, DAo
5 ( ) & 4 (a)/No Ca diac
coil
N/A
1450 Volume 53, No. 5
Jou nal o Magne ic Resonance Imaging

TABLE 1. Con inued
Pa ien Diagnosis
P e ious ca diac
p ocedu es
Weigh
(kg)
Slice
hickness/
pSAT flip
angle Hea s uc u es ca he e ized
Size o balloon wedge
ca he e (F ench)/Use o
MRI compa ible wi e Coil
Scanning
me hod
25
a
HLHS •Single en icle
pallia ion –s/p Fon an
72 10 mm/40IVC, LL, SVC, RPA, LPA,
LPCW, RA, RV, AAo, DAo
6F ( & a)/Yes Ca diac
coil
iSui e
26 He e o axy, dex oca dia, AVSD, sup/in en icles,
pulmona y a esia wi h disconnec ed PAs
•Uni ocaliza ion o
MAPCAs + BTS
7.6 8 mm/30IVC, RA, LA, RV, LV, DAo,
AAo, BTS, LPA, RPA
5 ( ) & 4 (a)/No Flex M In e ac i e
27 TOF/absen pulmona y al e •Ao homog a ,
LeComp e maneu e
13.3 10 mm/40IVC, RA, RV, MPA, LPA,
RPA, RCPW
5/No Flex M In e ac i e
28 TGA, hypoplas ic RV •Single en icle –s/p
Fon an
17.4 10 mm/40IVC, LL, SVC, LPA, RPA 6/No Flex M In e ac i e
29 HLHS •Single en icle –s/p
Glenn
13.4 8 mm/40IVC, RA, RV, SVC, RPA,
LPA, LPCW
5 ( ) & 4 (a)/No Flex M In e ac i e
30 HLHS •Single en icle –s/p
Glenn
15.4 8 mm/40IVC, RA, RV, SVC, RPA,
LPA, LPCW
5 ( ) & 4 (a)/No Flex M In e ac i e
The size o he shea h e e s o he enous access unless specified o he wise.
a
These pa ien s unde wen dobu amine s ess s udy as well as PVR analysis.
(A) = a e ial access; ASD = a ial sep al de ec ; AAo = ascending ao a; AV = a io en icula ; AVSD = a io en icula sep al de ec ; BTS = Blalock-Taussig shun ; DAo = descending ao a;
DORV = double ou le igh en icle; HLHS = hypoplas ic le hea synd ome; IVC = in e io ena ca a; LA = le a ium; LL = la e al unnel; LPA = le pulmona y a e y; LPCW = le
pulmona y capilla y wedge; LPV = le pulmona y eins; LV = le en icle; MAPCA = majo ao opulmona y colla e al a e y; PAs = pulmona y a e ies; RA = igh a ium; RPA = igh pul-
mona y a e y; RPCW = igh pulmona y capilla y wedge; RUPA = igh uppe pulmona y a e y; RMPA = igh middle pulmona y a e y; RLPA = igh lowe pulmona y a e y; RV = igh
en icle; RVOT = igh en icula ou flow ac ; SVC = supe io ena ca a; TGA = ansposi ion o he g ea a e ies; TOF = Te alogy o Fallo ; ( ) = enous access; VSD = en icula sep-
al de ec .
May 2021 1451
Velasco Fo e e al.: iCMR in Congeni al Hea Disease
Demog aphic ea u es and hemodynamic findings a e
summa ized in Table 2. Among all ec ui ed pa ien s, 11 we e
emales. The median age was 4 yea s ( ange: 2 mon hs o
39 yea s), median weigh was 15.2 kg ( ange: 5–98 kg),
median body su ace a ea (BSA) was 0.65 m
2
( ange:
0.27–2). Twen y pa ien s had p e ious majo ca diac su ge y.
Th ee needed a dobu amine s ess s udy in addi ion o base-
line PVR analysis. Se en unde wen igh hea ca he e iza-
ion, 11 needed bo h igh and le hea assessmen , and he
es o he pa ien s
12
we e single en icle ana omies needing
ca he e iza ion o he Fon an (se en cases) o HemiFon an/
Glenn (fi e cases) ci cula ion and in aca diac p essu es.
In ou ec ui ed pa ien s a he beginning o he s udy,
MRI guidance was no pe o med owing o he p edic able
need o a wi e in a pa ien wi h a c iss-c oss hea and se e e
al a and sub al a pulmona y s enosis, he pa ien ’s clinical
ins abili y (pe sis en pulmona y hype ensi e c isis), and he
a i ac caused by he exis ing s en s in he pulmona y essels
in wo pa ien s wi h single en icle ci cula ion.
The mean adia ion dose and ime we e 0.42 0.58
mGym
2
and 10.02 11.36 minu es, espec i ely. The o al
p ocedu e ime (skin in –skin ou ) was 219 52 minu es.
The median baseline pulmona y ascula esis ance was 2.3
WU.m
2
( ange: 0.28–32.6). These alues educed o a
TABLE 2. Summa y o Demog aphic Fea u es and
Ca he e iza ion De ails in Rec ui ed Pa ien s
Age (median, ange)
4 yea s (2 mon hs o
39 yea s)
Body su ace a ea (median,
ange)
0.65 m
2
(0.27–2)
Weigh (median, ange) 15.2 kg (5–98)
Heigh (median, ange) 102 cm (58–175)
P e ious ca diac p ocedu e 20/30 pa ien s
Hea a e 98 28 bpm
Ca he e isa ion ime (skin
in-skin ou )
219 52 minu es
Indexed adia ion dose 0.42 0.58 mGym
2
Radia ion ime 10.02 11.36 minu es
Measu emen s a e shown as mean SD unless s a ed
o he wise.
FiO2 = ac ion o inspi ed oxygen; iNO = inhaled ni ic oxide;
ppm = pa s pe million; PVR = pulmona y ascula esis ance.
FIGURE 2: E ec o changes in pSAT angle (30,40
, and 50) and slice hickness (5, 7, 8, and 10 mm) in balloon, blood, and
myoca dium SNR (a,b) and balloon/blood, balloon/myoca dium and myoca dium/blood CNR (c,d) ac oss di e en pa ien s.
1452 Volume 53, No. 5
Jou nal o Magne ic Resonance Imaging
median PVR o 1.9 WU.m
2
( ange: 0.63–27) in esponse o
inhaled asodila o s.
Indi idual Adjus men o he pSAT Sequence in
Clinical Cases
The in i o e ec o changes in pSAT angle (30,40
, and
50) and slice hickness (5, 7, 8, and 10 mm) in balloon,
blood, and myoca dium SNR and balloon/blood, balloon/
myoca dium and myoca dium/blood CNR a e summa ized
in Fig. 2. Only one se o pSAT angle/slice hickness was
acqui ed o each subjec ; he e o e, each plo ep esen s a di -
e en pa ien .
Slice hickness and pSAT angle o each pa ien a e
desc ibed in Table 1. Bo h ea u es we e adap ed indi idually.
In one case, he slice hickness was 5 mm. This was a small
pa ien (weigh 12 kg) wi h se e e PA b anches s enosis
FIGURE 3: Images acqui ed wi h iSui e in a pa ien wi h Te alogy o Fallo and LPA s en . An inc ease in he pSAT angle om 30
( op image) o 45(bo om image) imp o ed he conspicui y o he balloon- ip by inc easing he con as be ween blood and
balloon.
May 2021 1453
Velasco Fo e e al.: iCMR in Congeni al Hea Disease
associa ed wi h Allagile’s synd ome (minimum LPA and RPA
diame e we e 5 and 6 mm, espec i ely). Fo he es o he
cases, he slice hickness anged om 7–10 mm and was
adap ed acco ding o he pa ien ’s weigh and ca diac s uc-
u es’size. The pSAT angle o achie e pa ial sa u a ion was
also op imized in each case, a ying om 30 o 50.In
pa ien s wi h small pulmona y a e ies, he u bulen flow
p e en ed depic ion o he balloon ip using low pSAT angles.
This was pa icula ly e iden in a pa ien wi h Te alogy o
Fallo and LPA s en , in whom bo h pulmona y a e ies we e
slende all along hei cou se. An inc ease in he pSAT angle
om 30 o 45imp o ed he isualiza ion and allowed con-
inua ion o he s udy (Fig. 3, Video S1 in he Supplemen al
Ma e ial). A slice hickness o 20 mm and a pSAT angle o
120was used in wo cases o find he balloon du ing eal-
ime MRI ca he e iza ion. Once he balloon was loca ed, he
plane o isualiza ion was ans e ed up o he balloon ip,
and he slice hickness and pSAT angle con e ed o he one
ini ially selec ed.
The olume injec ed in he balloon a he ip o he
wedge ca he e was adap ed no only o each pa ien bu
acco ding o he size o he na iga ed s uc u es du ing he
cou se o he case. Al hough ini ially infla ed o he maximum
olume ecommended by he manu ac u e , in nume ous
occasions i had o be pa ially defla ed o c oss he pulmo-
na y al e o o ca he e ize he pulmona y b anches.
Visualiza ion Du ing Real-Time MRI-Guided
Ca he e iza ion
The iSui e pla o m was used in 16 pa ien s. In 10, he pSAT
sequence was used in in e ac i e mode in he scanne console,
as he iSui e was no a ailable. In one pa ien , ca he e enous
access was om he neck essels wi h simul aneous need o a
le hea ca he e om a emo al a e ial app oach. This lim-
i ed sa e isualiza ion o he iSui e sc een om he head end
o he MRI bo e in he cu en se -up o he labo a o y.
Visualiza ion o he balloon a he ip o he ca he e
was achie ed in all he s udies. Du ing eal- ime MRI ca he-
e iza ion, he balloon was isible h oughou 57 21% o
he scanning ime. The iSui e pla o m allowed o isualiza-
ion in he h ee planes o space, wi h a significan imp o e-
men in he ime du ing which he balloon was isible in
ela ion o he in e ac i e imaging mode on he scanne
console (iSui e: 66 17% s. in e ac i e mode: 46 
14%, P< 0.05).
O e all, he sco e o balloon/blood con as and ana-
omical isualiza ion was good o excellen , achie ing a
median o 4 ( ange: 2–5) and 5 ( ange: 2–5), espec i ely.
High sco es o bo h we e ob ained independen o he use o
he pSAT sequence embedded in iSui e o as in e ac i e mode
in he scanne console (Wilcoxon es : compa ison be ween
balloon/blood con as wi h iSui e o in e ac i e mode,
P= 0.385; ana omical isualiza ion, P= 0.5).
Th ee pa ien s ecei ed a sco e o 2 o ana omical isu-
aliza ion. O no e, all h ee we e a he ex eme side o he
weigh ange in ou popula ion ( wo o hem we e less han
8 kg, one o hem was o e 95 kg). A o al o 91% o sco es
gi en o ana omy depic ion we e ≥3; he weigh ange o
hese pa ien s was 10–60 kg. Al hough no significan di e -
ence was no ed, a end o ob ain highe sco es was ound o
ana omical isualiza ion in ela ion o pa ien ’s weigh
(P= 0.053). Simila alues we e obse ed when balloon/
blood con as sco ing was compa ed among di e en weigh
g oups (P= 0.483) (Fig. 4).
Two pa ien s in whom he MRI ca he e iza ion was
guided wi h he pSAT sequence on in e ac i e mode ecei ed
a sco e o 2 o con as . In all p ocedu es guided by iSui e,
con as be ween balloon and pa ien ’s ana omy was sco ed
FIGURE 4: Mean sco es o ana omical isualiza ion and balloon/
blood con as sco es acco ding o pa ien ’s weigh . Be e
sco es we e achie ed o pa ien s wi h weigh be ween
10 and 60 kg.
FIGURE 5: To al pe cen age o pa ien s ecei ing a sco e o
2 (9 and 5%), 3 (23 and 12%), 4 (42 and 23%), and 5 (26 and
59%) o ana omical and balloon/blood con as isualiza ion,
espec i ely.
1454 Volume 53, No. 5
Jou nal o Magne ic Resonance Imaging