Radiology of the Heart: Cardiac Imaging in Infants, Children, and Adults

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1. Introduction

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Request an Appointment Refer a Patient. Radiology Why Us? Both methods suffer from potentially introducing misregistration artifacts or field inhomogeneity. An increasingly used method for fat suppression, the Dixon technique, relies on the phase shifts that occur due to resonance frequency differences between water and fat by acquiring images at carefully chosen echo times. This technique has been shown to give improved imaging at 1. Field homogeneity is difficult to achieve for whole heart coronary imaging at higher field strengths. This has a major impact on image quality. Therefore, the Dixon technique may offer even greater superiority over the traditional fat suppression techniques at 3.

Figure 2. Example of Dixon water—fat separation technique. Reformatted coronary images demonstrating quality and superior fat suppression achieved using Dixon technique at 3 T. For CHD imaging, fluid in the pericardial recesses can also cause interference with the diagnostic quality. One approach to overcome this is the use of an inversion pulse to reduce the signal from long T1 species. In addition, the null point can be set at or around the myocardium to reduce myocardial signal and obviate the need for a T2-preparation pulse.

This requires shortening of the T1 time of blood by injection of a gadolinium-based contrast agent. Given the risk of contrast washout with a long acquisition time for the whole heart sequence, blood pool contrast agents have been used. Makowski et al. From a clinical standpoint, 3D inversion recovery SSFP imaging approach has produced the most reliable image quality, improving the ease of generating 3D models for computational simulation or 3D printing Figure 3 ; Video S1 in Supplementary Material. There has been some debate as to whether this 3D whole heart inversion recovery is better with SSFP, which may give more signal, or with a spoiled gradient echo sequence, which may give greater T1-weighting allowing for more effective contrast in the presence of a blood pool gadolinium chelate.

This was evaluated by Febbo et al. However, there may be certain advantages of using a spoiled gradient echo approach, namely in terms of reduced susceptibility artifacts with metallic implants Furthermore, at 3 T, SSFP sequences suffer from artifacts due to the greater field inhomogeneity at this field strength. Not surprisingly, spoiled gradient echo 3D whole heart has been shown to be superior at 3 T Video S2 in Supplementary Material Figure 3.

Example inversion recovery three-dimensional spoiled gradient echo using gadofosveset trisodium image showing novel Y-graft cavopulmonary connection and inferior vena cava stent. Spoiled gradient echo techniques show less susceptibility artifact and may be preferable for this reason. The left hand image shows source images, and the volume-rendered segmentation is shown on the right. Although providing excellent image quality, there are two problems with the inversion recovery whole heart and blood pool agent approach. First, myocardial late enhancement imaging is not possible, and second, there are currently no intravascular blood pool agents being manufactured.

One possible strategy is to use gadobenate dimeglumine, which has been shown to produce similar images as gadofosveset 23 given its partial albumin-binding characteristics. However, given its linear nature, there are theoretical concerns regarding a higher risk of central nervous system deposition 24 and nephrogenic systemic fibrosis than with macrocyclic gadolinium compounds For this reason, Tandon et al.

The Role of Cardiovascular Magnetic Resonance in Pediatric Congenital Heart Disease

Gadobutrol is a widely used extracellular contrast agent that is macrocyclic. By administering it by slow infusion, Tandon et al. Moreover, they demonstrated that it can be simultaneously used for myocardial late enhancement Figure 4. Example images produced with gadobutrol slow infusion technique.

Pediatric Cardiac Imaging

Image quality for slow infusion protocol with inversion recovery steady-state-free-precession three-dimensional whole heart imaging can be excellent. The inversion pulse removes signal from fluid in the pericardial recesses resulting in superior vessel sharpness. Besides the motion artifacts induced by cardiac pump activity and pulsatile arterial flow patterns, respiratory motion is also inevitable in free-breathing imaging techniques.

The first step toward correcting motion is to be able to measure it.

This is commonly achieved by means of a respiratory navigator. This is a real-time image acquisition, which is interleaved with the high-resolution whole heart sequence, providing snapshots of the respiratory position before or after each segmented whole heart k-space acquisition. The vast majority of motion occurs in a foot—head direction, but important motion can occur in the anteroposterior and left—right directions The most widely used approach for whole heart imaging is a one-dimensional diaphragmatic 1D navigator This consists of a narrow excitation pulse, typically placed at the dome of the right hemi-diaphragm, measuring the foot—head motion using a 1D representation of the lung—liver interface.


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However, this approach does not estimate true heart displacement, as the foot—head motion of the diaphragm is greater than the heart foot—head motion. Therefore, a correction factor of 0. There are two problems with this estimation. First, the amount of heart motion compared to the diaphragm varies from individual to individual. In fact, such complex motion models relating diaphragmatic to heart motion exist and are known as affine motion models, but implementation on patient-specific basis is cumbersome Commercially available whole heart imaging sequences use a 1D diaphragmatic navigator, which requires a separate excitation pulse, coupled to the whole heart pulse sequence.

It also requires dedicated planning alongside the imaging volume. More recently, novel approaches have been described using simply the whole heart data itself to correct for motion. It has the advantage of being able to correct motion in not only the foot—head dimension, but also in all three dimensions Typically, self-navigation uses a 1D projection of the FOV and so static tissue such as the chest wall is also included in the navigator image, which may interfere with the motion estimation.

One method to avoid this is to confine the projection to the area of interest e. This type of motion compensation has been applied to CHD imaging with favorable results. Henningsson et al. The approach used by Henningsson et al. Hence, no further image planning or acquisition was required. Furthermore, there was no need to extend the pulse sequence design.

The implementation obviated the need for dedicated navigator planning and reduced significantly the acquisition time while improving image quality. Figure 5 shows representative images showing how image-based navigation was able to depict the distal RCA.

Peripheral Vascular Disease: Should it be CT or MRI Imaging? (FAISAL NABI, MD)

This type of image navigation is capable of correcting rigid motion in the foot—head and the left—right directions. More recently, image-based self-navigation has been implemented, which corrects for rigid and non-rigid motion in all three-dimensions This type of 3D affine motion correction is currently computationally demanding, and hence difficult to implement widely.

Introduction

Figure 5. Example images using self-navigation technique. These acceleration methods have allowed data acquisition of a complete 3D dataset in currently less than 5 min Currently, parallel imaging is the most commonly used acceleration technique with an acceleration factor of 2 Accordingly, the segmental approach used to diagnose CHD can be easily applied retrospectively 35 , Moreover, the detailed 3D dataset can be used to plan further sequences e. This makes this method user-independent to diagnose structural heart disease Initially, the successful use has been demonstrated in adolescents and young adults 35 , but with improved data acquisition techniques, infants of 4 months and older were successfully imaged using 3D whole heart imaging, both with the single phase 37 and the dual-phase approach Importantly, magnetization preparation schemes have allowed arterial and venous structures to be assessed simultaneously in the majority of cases, regardless of the use of a contrast agent Figure 6 shows Fontan pathways imaged without contrast agent use.

This is a great advantage compared to CT, where high-quality coronary and vascular imaging is limited to the first pass of iodinated contrast and timed for a specific region of interest. Currently, CT studies are therefore targeted to a specific vascular structure such as the coronaries, the aorta, the pulmonary arteries, etc. Furthermore, despite dramatic reduction in ionizing radiation with current technologies, imaging tends to be limited to one phase if heart rate enables prospective gating.

Figures 6 — 8 show the advantage of cardiac MRI, which is able to image both arterial and venous phases with high image signal and CNRs, while avoiding administration of contrast agents. Figure 6.

Radiology | Phoenix Children's Hospital

Lateral tunnel Fontan pathways imaged using non-contrast three-dimensional 3D balanced steady-state-free-precession SSFP technique. Figure 7. D-TGA after atrial redirection surgery Senning. Systemic venous return redirected to the left ventricle LV , i. Atrial baffle redirecting pulmonary venous return to the right atrium, i.

Also shown is how the intraatrial systemic venous Senning pathway returning to the LV is compressed in the anterior—posterior dimension.

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