JAN BOGAERT Teaching Cases CLINICAL CARDIAC MRI SECOND EDITION
Cases 61-80
Slide 2
ASD type secundum Univentricular heart Membranous VSD Muscular
VSD Uncorrected TOF TOF + Waterston Anastomosis Corrected TOF with
severe PR TOF+ severe subvalvular PS Decompensated TOF TOF with
MAPCAs TOF + myocardial infarction LV dysfunction in TOF patient
Ebsteins Disease Complex CHD Partial non-expansion or agenesis RV
Giant aneurysm of sinus of Valsalva Fontan circulation Persistent
ductus arteriosus Situs inversus totalis Incidental finding of CHD
in patient with severe AS Scimitar vein
ASD Type Secundum 33-year-old woman with large type secundum
ASD. Baseline cardiac MRI (left panel): LV EDV 96 ml SV 54 ml EF
56% / RV EDV 319 ml SV 159 ml EF 49%. Flow Ao 57 ml/hb PT 178 ml/hb
Qp/Qs > 3. Dilated PT. Large, multifenestrated ASD. Normal
entrance of pulmonary veins in LA MRI post ASD closure(right
panel): LV EDV 127 ml EF 75% / RV EDV 143 ml EF 61%. Flow Ao 86
ml/hb PT 91 ml/hb. Qp/Qs = 1. See similar case Fig. 13 Congenital
Heart Disease
Slide 5
Univentricular Heart 39-year-old man with complex CHD:
congenitally corrected TGA (L-TGA), double inlet left ventricle
(DILV), VSD, non-restrictive univentricular heart (UVH), dominant
LV, rudimentary RV, and PS. Cardiac MRI : UVH EDV 405 ml EF 59%,
globally well preserved myocardial contractility. PS (PC-MRI: 56 mm
Hg) with post-stenotic dilation of PT (57 mm).
Slide 6
Membranous VSD 20-year-old woman with known membranous VSD,
cardiac US shows gradient of 80mm Hg over VSD, no evidence of PAHT.
Cardiac MRI: LV EDV 197 ml SV 129 ml EF 66% / RV EDV 105 ml SV 65
ml EF 60%. PC-MRI, Ao flow 57 ml/hb PT 135 ml/hb, yielding Qp/Qs of
2.36. Presence of membranous VSD with systolic jet (arrow, right
panel). The RV is non-dilated and non-hypertrophied while the LV
EDV and SV are more than two-fold the EDV and SV of RV. See also
Fig.16 and Table 5 Congenital Heart Disease
Slide 7
Muscular VSD 73-year-old woman with history of mitral and
tricuspid valve repair for MR / TR, persistence and gradual
increase of dyspnea. Cardiac MRI: LV EDV 180 ml EF 57% - SV 103 ml
/ RV EDV 245 ml EF 22% - SV 54 ml. LR-shunt, flow ascending aorta
53 ml/hb pulmonary trunk 112 ml/hb (Qp/Qs = 2). Thinned appearance
of apical ventricular septum with multi-fenestrated VSD (see
dark-flow zones PC-MRI, right middle panel). Though the etiology of
the muscular VSD in this elderly woman is uncertain, a myocardial
infarction is the most likely hypothesis.
Slide 8
Uncorrected Tetralogy of Fallot 38-year-old woman with
tetralogy of Fallot, pulmonary valve atresia, VSD, right aortic
arch, major aortic pulmonary collateral arteries (MAPCAs). LV EDV
260 ml EF 58% / RV EDV 290 ml EF 44% - moderate to severe
hypertrophy. Big outlet VSD (22mm). Overriding aorta. Dilated
ascending aorta (51x48 mm) with moderate AR (regurgitant fraction
10%) severe TR.
Slide 9
Tetralogy of Fallot + Waterston Anastomosis 41-year-old woman
known with Waterston anastomosis for tetralogy of Fallot,
presenting with Eisenmenger syndrome, right heart failure, cardiac
cirrhosis and chronic renal insufficiency. Cardiac MRI: LV EDV 128
ml EF 47% / RV EDV 260 ml EF 47% - severe RV hypertrophy. Large
membranous VSD. Hypoplastic RVOT hypoplastic PV. Severe TR (PC-MRI:
80 ml) with RA/IVC dilatation. Atrial septal aneurysm. Dilated
aortic root. Right aortic arch with mirror-image branching.
Waterston anatomosis with bidirectional flow (video right
panels).
Slide 10
Tetralogy of Fallot with Severe PR 22-year-old woman with
surgically corrected tetralogy of Fallot (infundibular resection)
send for cardiac MRI study to evaluate severe PR and RV
volumes/function. LV EDV 162 ml EF 47% / RV EDV 300 ml EF 35 % -
diffuse hypokinetic wall motion. Diastolic flattening of
ventricular septum. Severe PR (PC-MRI, right panel: regurgitant
volume 45 ml).
Slide 11
Tetralogy of Fallot with Severe Subvalvular PS 11-year-old boy
with surgical repair tetralogy of Fallot (infundibular patch),
Melody valve for PS, presenting with residual subvalvular PS.
Cardiac MRI shows muscular subvalvular PS with minimal diameter
(5.5x9.5mm), and a peak velocity of 4.5 m/s (gradient of 64 mm Hg).
Severe RV hypertrophy but preserved myocardial contractility (RV
EDV 123 ml EF 58%). Presence of Melody valve. Since RFA is
unsuccessful, surgical resection of subvalvular PS performed,
showing a prominent muscular ring in RVOT.
Slide 12
Decompensated Tetralogy of Fallot 45-year-old man with
surgically corrected TOF, admitted with diastolic heart failure.
Cardiac MRI shows moderately dilated RV (EDV 240 ml) with preserved
systolic function (EF 66%), presence of moderate PR (19%), TI and
mild PS. Focally thickened pericardium with some compression of
inferolaterobasal wall. Cardiac CT shows heavily calcified
pulmonalis homograft, focally thickened and calcified pericardium
constricting RV. Surgery: redo pulmonalis homograft, TV plasty and
pericardiectomy.
Slide 13
Tetralogy of Fallot + MAPCAs 40-year-old man with uncorrected
TOF, PV atresia, subaortic VSD, MAPCAs, pulmonary hypertension, AR
(3-4/4) treated with AV prosthesis, dilated ascending Ao, right
aortic arch. NYHA III. LV EDV 357 ml EF 41% / RV EDV 252 ml EF 42%
- severe RV hypertrophy. AR 27%, dilated aortic root 56 mm,
complete agenesis RVOT - PV. Multiple MAPCAs originating from
aortic arch and descending Ao supplying pulmonary circulation. CT
(performed after AV replacement) nicely shows the number, origin,
and course of the MAPCAs. See similar case Fig. 22 Congenital Heart
Disease
Slide 14
Tetralogy of Fallot + Myocardial Infarction (1) 43-year-old man
with corrected TOF presenting extensive inferior MI (late
presentation), secondary MR and heart failure. LV EDV 280 ml EF
32%, thinning of entire LV inferior wall with a-dyskinetic wall
motion. RV EDV 279 ml, EF 32%, moderate to severe hypokinesia.
Severe MR and TR, small PR. Small LV apical thrombus.
Slide 15
Tetralogy of Fallot + Myocardial Infarction (2) Late Gd imaging
shows almost complete transmural enhancement of LV inferior wall
(segments 3,4,9,10,15)(arrows, right panels). Enhancement of
anterolateral LV papillary muscle (arrowhead right panel) Small
apical thrombus (arrowhead, middle panels). Severe MR and TR
(arrows, left panel).
Slide 16
LV Dysfunction in Fallot Patient (1) 35-year-old man with
history of surgical repair for tetralogy of Fallot, presenting with
LV dysfunction, and presence of emboli in LCx and distal LAD
coronary artery. Cardiac MRI: LV EDV 198 ml - EF: 37% - hypokinesia
in ventricular septum and in (thinned) lateral wall. RV EDV 185 ml
EF 47%. Moderate PS (36 mm Hg) and PR (34%). Late Gd imaging shows
extensive transmural enhancement in anteroseptal wall (segments
2,89,14,17) and lateral wall (segments 5,6,11,12,16) with presence
of microvascular obstruction. Enhancement of the RV anterior free
wall. Findings of acute extensive infarction in two perfusion
territories. No etiology for the emboli found.
Slide 17
Follow up MRI study, 4 months after, shows adverse RV and LV
remodeling, RV EDV 234 ml EF 38% / LV EDV 239 ml EF 30%. Thinning
of the infarcted areas with disappearance of microvascular
dysfunction. In particular the LV lateral wall has become
dyskinetic (whereas initially severely hypokinetic). LV Dysfunction
in Fallot Patient (2)
Slide 18
Ebsteins Disease 4-year-old girl with Ebsteins disease. Apical
implantation (41 mm) of septal leaflet of tricuspid valve with
atrialization of RV. Secondary TR (2/4). Small perimembranous VSD.
Small PFO. See similar case Fig. 35 Valvular Heart Disease
Slide 19
Complex CHD 54-year-old man presenting with complex congenital
heart disease (CHD): situs solitus, levocardia, double discordance,
VSD with bidirectional shunt, Ebstein malformation. Severe
pulmonary hypertension. LV EDV 391 ml EF 50% - diffuse hypokinesia
/ RV EDV 491 ml EF 26% - diffuse hypokinesia. Severe TR. Massive
dilatation of both atria.
Slide 20
Partial Non-Expansion or Agenesis of RV 32-year-old woman with
Ebsteins disease and Glenn surgery (SVC to right PA, RV to left
PA). Closure of ASD type II. Impression of excluded RV apex by
muscular structure. Cardiac MRI shows severe hypertrophy of
trabecular/muscular structures in RV apex (arrow) with almost
complete obliteration of the cavity. Presence of a notch between
basal and apical part of RV (arrowhead). Severe dilatation of RV,
IVC and coronary sinus. Important TR (28 ml/heart beat). Surgical
repair of displastic tricuspid valve and resection of muscular
structures in RV apex.
Slide 21
Giant Aneurysm of Sinus of Valsalva 57-year-old woman with
incidental finding of annulo-aortic ectasia (max. 56 mm). The
patient mentions a history of car accident (eight years before).
Cardiac MRI shows giant aneurysm of sinus of Valsalva orginating
from non- coronary cusp (diameter 58x34 mm) prolabating in RA. No
evidence of rupture of aneurysm. Moderate AI. Surgical resection of
aneurysm and aortic valve replacement.
Slide 22
Fontan Circulation 40-year-old man with history of large inlet
VSD, hypoplastic bipartite RV without apex, TGA, PS, TR. Right
aortic arch. Fontan total cavo-pulmonary connection (TCPC) at age
19 years. Cardiac MRI EDV 127 ml SV 72 ml - EF 57% (combined
RV/LV). Dilated aortic root, flow ascending aorta: 68 ml/hb.
Inferior cavopulmonary connection (arrow right middle panel): flow
44 ml/hb. Superior connection (arrow, right panel): flow 26 ml/hb.
Flow right PA 41 ml/hb left PA 34 ml/hb.
Slide 23
Patent Ductus Arteriosus 39-year-old man with unsuccessful
closure of patent ductus arteriosus (age 12 years), currently
presenting with Eisenmenger syndrome (Hct 70%, sat. 60%). NYHA
class III. Small intramuscular VSD. Cardiac MRI: LV EDV 116 ml EF
32% / RV EDV 236 ml EF 27% - severe RV wall hypertrophy. Inversion
of ventricular septum with paradoxical motion. Severe TR (39%),
moderate MR (26%) and AR (18%). Dilated RA. Patent ductus arterious
(22 mm) with bi-directional shunt. Dilatation of proximal
descending aorta (40 mm). Dilated pulmonary trunk.
Slide 24
Situs Inversus Totalis 37-year-old woman with dextracardia and
situs inversus totalis. Cardiac apex oriented to right side.
Right-sided position of morphologic LV. Normal atrioventricular and
ventriculoarterial concordance. Right-sided aortic arch. Normal
ventricular volumes and systolic function. Left-sided position of
liver, right-sided position of spleen.
Slide 25
Incidental Finding of CHD in patient with severe AS 50-year-old
woman presenting with dyspnea (NYHA II-III), history of aortic
coarctation (coarctectomia) and progressive AV stenosis. Cardiac US
shows severely degenerated AV valve with PIG of 70 mm Hg and
calculated AV orifice of 0.5 cm2. Cardiac MRI: dilated RV (EDV 239
ml SV 144 ml EF 60%) / LV EDV 75 ml SV 43 ml EF 57%. Intact
appearance of atrial septum but partial abnormal pulmonary venous
drainage of right upper/middle lobe vein to SVC. Ascending aorta:
42 ml/hb pulmonary trunk: 139 ml/hb (Qp/Qs: 3.25). Bicuspid aortic
valve with peak flow of 3.2 m/s (gradient 41 mm Hg). MV prolapse.
Persisting left SVC
Slide 26
Scimitar Vein 9-year-old boy with Scimitar syndrome, PAPVR,
dextrocardia, situs solitus. Large vein (Scimitar vein, arrowheads
left panel) draining right lower lobe in IVC. Surgical rerouting of
abnormal vein toward LA.