Imaging Cardiovascular Disease in Pregnancy

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1 Imaging Cardiovascular Disease in Pregnancy Karen Ordovas MD, MAS Associate Professor of Radiology and Medicine Director of Cardiac Imaging University of California San Francisco

2 Cardiac MRI during pregnancy When it cant be postponed Risk stratification for mother and offspring Recommendation for pregnancy interruption Inform best form of delivery Indicate level of cardiovascular care during delivery and postpartum

3 Outline Tips and tricks Most common indications

4 CMR during pregnancy Tips and Tricks Challenging task Altered hemodynamics Preference not to use Gadolinium Difficulty breath- holding Cardiac coil may not fit properly Discomfort laying prone

5 Cardiac MRI during pregnancy Tips and Tricks First things first: Main clinical question Take advantage SSFP images in multiple planes or 4D Free- breathing sequences Non- gadolinium MRA Fast 3D acquisitions

6 Okuda et al J Toxicol Sci 1999 Webb et al Eur Radiol, 2005 Chen etal. Obstet Gynecol, 2008 Safety Considera/ons Gadolinium Crosses the placenta, excreted by fetal kidneys into amniotic fluid and swallowed Toxic free gadolinium (minimal) Mother/Fetus concentration: 100/1 Sporadic evidence of animal teratogenesis No report of teratogenesis in humans Risk of nephrogenic systemic fibrosis (NSF) to fetus unknown

7 Safety Considera/ons Gadolinium US FDA Category C agent Administered if the potential benefit justifies the potential risk to the fetus American College of Radiology: 1. No sufficient evidence to conclude no risk 2. Gadolinium should NOT be given unless absolutely necessary 3. Clinical discussion should be documented in report and patient informed consent should be obtained 4. Use agents considered low risk for NSF Thomsen HS. Eur Radiol 2013 ACR Contrast Media Manual 2015 Halvorsen et al Radiology 2008 Webb et al Eur Radiol 2005

8 Non- Gad MRA 3D SSFP Navigator compensated EKG gated 5 min acquisition

9 Accelerated 4D cine images 3 minute free breathing acquisition Jing Liu, David Saloner. Quant Imaging Med Surg. Feb 2014; 4(1):

10 Indications for CMR during pregnancy When CMR is better than Echo Aortic imaging Dissection Aneurysm Adults with CHD Coarctation Complex CHD ACR Contrast Media Manual 2010 Halvorsen et al Radiology 2008 Webb et al Eur Radiol 2005

11 UCSF CMR in Pregnancy 10 years Aortic dissection Aortic dimesnion Complex Congenital heart disease Pulm Hypertension - Shunt Coronary anomaly Heart as source of stroke

12 Aortic Dissection in Pregnancy Rare complication, but 10% of maternal death Increased risk in: Bicuspid aortic valve Coarctation Collagen vascular disease Usually 3rd trimester or peripartum CMR ideal for diagnosis and extent Steady state free precession Wanga S et a l. Can J Cardiol 2016 Jan;32(1): V. Regitz- Zagrosek et al. Eur Heart J 2011; 32:

13 Aortic Dissection in Pregnancy Subacute IMH 3rd trimester Resolved IMH Postpartum

14 Dimensions of the aorta and risk of dissection High risk of dissection if > 50 mm in BAV Connective tissue disease >45 mm Pregnancy interruption recommended in first trimester! Bowater SE, Thorne SA. Postgrad Med J 2010;86:100 5 Non-Contrast MRA

15 Adults with CHD Increasing population of females in childbearing age Frequently present to cardiologist already pregnant Balanced hemodynamics may decompensate 40-50% Plasma volume at 24 weeks gestation 30 50% CO; 30% Heart size Increase risk of thromboembolic complications Virchow's triad: hypercoagulability, venous stasis, and vascular damage An/coagula/on may need to be discon/nued Mendelson, M, Glob. libr. women's med., 2008

16 Key information for risk stratification by CMR in ACHD Function of the systemic ventricle High mortality rate if LVEF<40% Risk of permanent ventricular damage in systemic RV is high if dilated and low EF Status of conduits, baffles, anastomosis Function of the pulmonary and aortic valve Mainly obstructive lesions (gradient > 30mmHg) Bowater SE, Thorne SA. Postgrad Med J 2010 Guedes A, JACC 2004 V. Regitz- Zagrosek et al. Eur Heart J 2011

17 Key information for risk stratification by CMR in ACHD Pulmonary hypertension in pregnancy 30-56% mortality Echocardiography first line CMR documenting Eisenmenger physiology may be useful for risk prediction during pregnancy Bedard E, European Heart Jourma 2009 Bowater SE, Thorne SA. Postgrad Med J 2010

18 35 y/o status post TOF repair 28 weeks gestation Echo suggests enlarged aorta Focused MR study with SSFP cine images only

19 26 y/o d- TGA, s/p Mustard Lower extremity edema and shortness of breath Focused SSFP Cine in plane aligned to baffle

20 29 y/o coarctation post- stent with hypertension Evaluate stent patency T1- weighted FSE Non- Gad MRA

21 VEC-MRI no Collateral Flow 400 Proximal 200 Flow (ml/sec) Distal Phase of Cardiac Cycle

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23 Summary Cardiovascular Imaging in pregnancy Only if cant be postponed Can be performed safely, but gadolinium not recommended Pregnancy risk stratification Main applications in aortic disease and complex congenital heart disease

24 Thank You