CARDIAC MRI ANATOMICAL AND FUNCTIONAL ASSESSMENT OF STENTING PULMONARY BRANCHES IN OPERATED TETRALOGY OF FALLOT

Transcription

1 XLI CONGRESSO NAZIONALE SOCIETÀ ITALIANA DI CARDIOLOGIA PEDIATRICA Bari Ottobe 2011 CARDIAC MRI ANATOMICAL AND FUNCTIONAL ASSESSMENT OF STENTING PULMONARY BRANCHES IN OPERATED TETRALOGY OF FALLOT L Ait - Ali, V De Lucia, S Cost a, D De Marchi, P Fest a U. O. Cardiologia pe diat rica Ospedale del cuore- MRI L LAB FTGM- CNR Massa- Pisa

2 Background Percutaneous stent implantation is a valid alternative to surgery for the treatment of stenotic pulmonary arteries in Tetralogy of Fallot (TOF). Indications to and results of pulmonary stent implantation are classically assessed by means of Nuclear scan CV Magnetic Resonance (CMR) is a non-invasive, radiation free, validated tool for the assessment of pulmonary arteries anatomy and flow. Metallic artefact coming from the stent limits CMR accuracy.

3 Aim 1- To compare Nuclear scan to CMR in the assessment of differential pulmonary flow. 2-To evaluate the efficacy of CMR to visualize the pulmonary stent by means of dedicated sequences. 3- To evaluate the hemodynamic effect of pulmonary branches stent on pulmonary branches flow, pulmonary regurgitation, RV volume and RVEF.

4 Populat ion 26 operat ed TOF pt s post S t ent Age at st ent implant : 8, 8 years Age at st e nt e valuat ion: 15 ye ars 15 pt s LPA st ent 6 pt s RPA st ent 5 pt s RPA + LPA st ent 4

5 Prot ocol / Met hod - after stent implantation underwent: Nuclear scan (18/26) to evaluate - differential pulmonary perfusion. CMR (26/26) to evaluate - bi-ventricular volume, function, - pulmonary regurgitation, - pulmonary anat omy and f low

6 MRI Pulmonary flow Pulmonary perfusion: phase contrast pulmonary veins flow.

7 Result Correlation Right PVs flow-nuclear scan MRI Right PVs flow(%) Nuclear scan Right Pulm. (%)

8 Result Correlation Left PVs flow-nuclear scan MRI Left PVs flow(%) r: 0,9161 P<0,0001. Nuclear scan Left Pulm (%)

9 Aim 1- To compare Nuclear scan to CMR in the assessment of differential pulmonary flow. 2-To evaluate the efficacy of CMR to visualize the intrastent anatomy by means of dedicated sequences. 3- To evaluate the hemodynamic effect of pulmonary branches stent on pulmonary branches flow, pulmonary regurgitation, RV volume and RVEF.

10 Populat ion 26 operat ed TOF pt s post S t ent Age at st ent implant : 8, 8 years Age at st e nt e valuat ion: 15 ye ars 15 pt s LPA st ent 6 pt s RPA st ent 5 pt s RPA + LPA st ent 10 S t ainless st eel: 18 (69%) CP st ent : 3 (12%) Unknown: 5 (19%)

11 Met hod: CMR prot ocol MRI seque nces - Fast Spin Echo (black blood) - Cine MRI: - SSFP - GRE - MR angiography

12 Result FS E: Black blood. Stent LPA S t ent RPA S t ainless st e el st e nt CP st ent

13 Result Correlation FSEØ/ Ballon Ø Max Balloon Ø (mm) r: 0.88, p< 0,001). MRI FSE Ø (mm)

14 Result FS E: Black blood. Stent LPA S t ent RPA S t ainless st e el st e nt CP st ent

15 Result Cine MRI : S S FP. S t eel st ent CP st ent

16 Result Cine MRI : GRE S t eel st ent CP st ent

17 Result MR Angiography S t eel st ent P 3 08 CP st ent

18 Result GRE S S FP FS E MRA CP st ent

19 Result Cine MRI : GRE t hrough plane

20 Aim 1- To compare Nuclear scan to CMR in the assessment of differential pulmonary flow. 2-To evaluate the efficacy of CMR to visualize the pulmonary stent by means of dedicated sequences. 3- To evaluate the hemodynamic effect of stent on - Pulmonary flow and regurgitation, -RV pressure, volume and EF.

21 Populat ion 5/ 2 6 pt s MRI and Echo evaluat ion Pre and post ( year) St ent angioplast y Age: 5, 6 years ( ) 4 pt s LPA st ent 1 Pt RPA + LPA st ent

22 MRI pre and Post left Pulmonary flow % Pre-stent P < 0.01 Post-stent

23 MRI pre and Post RV Doppler systolic pressure Pre-stent Post-stent

24 MRI pre and Post Pre-stent Post-stent Pre-stent Post-stent Cardiac index (ml/min/m 2 ) RV ED vol (ml/m 2 ) RV EF(%) Pulm. Re gurg. Fract ion (%)

25 CONCLUSION 1-There is a good correlation between Nuclear scan and CMR in the assessment of differential pulmonary flow. 2- Through Plane GRE cine MRI is the best sequence for the visualitation of stented pulmonary arteries. The combination of different MRI sequences can help for excluding stent stenosis. 3- Pulmonary stent implantation leads to the improvement of ipsilateral flow 4- From our preliminary result seems that stenting the pulmonary artery does not influence Pulmonary regurgitation.

26 Ospedale del cuore G. Pasquinucci Massa IFC -San Cataldo Pisa

27 Method

28 MRI pre and Post left Pulmonary flow 33 ± 6.5% P < ± 7 %

29 MRI pre and Post 33 ± 6.5% P < ± 7 %

30 MRI pre and Post 37 ± 11 % 36.5 ± 5 % P ns

31 MRI pre and Post 137 ± 30 ml/m ± 27 ml/m 2 P ns

32 MRI pre and Post 137 ± 30 ml/m ± 27 ml/m 2 P ns

33 MRI pre and Post 56 ± 10 % P ns 53 ± 3 %

34 MRI pre and Post

35 MRI pre and Post

36 MRI pre and Post 33 ± 6.5% P < ± 7 %

37 Stent angioplasty Indication RV syst olic pressure 5 0% syst emic in bilat e ral st enoses Lung pe rf usion t o ipsilat e ral lung <20 % in unilat e ral st enosis I f pulmonary regurgit at ion pre sent or A lagille crit e ria less rigid

38 Stent nelle cardiopatie congenite stent nei rami polmonari Tipi: Stenosi unilaterale tubulare Stenosi unilaterale localizzata Bilaterale

39 Pulmonary arteries/stent patency FS E: Black blood. S t ent AP sin I nt rast ent Ge ne sis P 30 8 CP st ent

40 Pulmonary arteries/stent patency MR angiography S t ent AP dx P 3 08 Ge ne sis P 30 8 CP st ent

41 Pulmonary arteries/stent patency Ø (mm) Pre- st ent Origine: 3 x 4. 5 mm Distale: 8 x 8 mm Post st ent S t ent pervio AP sin Stent AP sin st ent Genesis 3 9

42 Pulmonary arteries/stent patency Ø (mm) Pre- st ent Origine: 2 x 2 mm Distale: 7 x 8 mm Post st ent S t ent pervio S porge nel t ronco medio AP dx Stent AP dx st ent Genesis 3 9 (acciaio in)

43 Pulmonary arteries/stent patency S t ent AP sin st ent P 30 8

44 Pulmonary arteries/stent patency

45 Pulmonary arteries/stent patency

46 Result FS E: Black blood X Ray angiography