Aortic Coarctation Imaging and Management in Adults Michael D. Hope, MD
1 Background 2 Imaging - Morphology 3 Imaging - Hemodynamics 4 Associations and Complications
Campbell M. British Heart Journal 1970 Coarctation Presurgical Era
Presurgical Era If coexisting BAV, 50% died of aortic dissection/rupture. Abbott ME. Am Heart Journal 1928 Campbell M. British Heart Journal 1970
Correctable Lesion Surgical repair 1 st described by Crafoord in 1945. Pediatric Congenital Cardiac Becomes a Postoperative Adult: The Changing Population of Congenital Heart Disease by Perloff JK Circulation 1973.
Coarct Surgeries 1. End-to-end 2. Subclav aortoplasty 3. Patch aortoplasy 4. Interposition graft 5. Bypass graft Ming-Chen et al. AJR 2005
Endovascular Repair Balloon angioplasty (1982): Restenosis and aneurysm formation. Use may be limited to discrete, shelf-like lesions Stenting: Now preferred. Older children and adults. Serial redilation possible.
Jenkins NP, Ward C QJM 1999 Coarctation Post Op Complications
1 Background 2 Imaging - Morphology 3 Imaging - Hemodynamics 4 Associations and Complications
Imaging Echocardiography CT MRI
Imaging - MRI Morphology: Coarct repair site. Type and dimensions of Ao arch. Aortic valve and left ventricle. Hemodynamics: Pressure gradient estimation. Collateral flow. Flow profile analysis. Post-intervention complications.
MR Imaging - MRA
MR Imaging - MRA MIP Subvolume MIP 3D Volume Rendering
MRI - Black Blood Oblique Sag SE MRA
MRI - Black Blood with Stent
MRA Arch Geometry Gothic Crenel Normal Ou P. et al. European Heart Journal 2004
MRA - Aortic Ratio < 0.9 hypoplasia, assoc w/ aneurysm at repair site > 1.5 high risk for progressive aneurysmal dilation
MRI - Aortic Valve Morphology
MRI - Left Ventricular Hypertrophy
1 Background 2 Imaging - Morphology 3 Imaging - Hemodynamics 4 Associations and Complications
Imaging - MRI Morphology: Coarct repair site. Type and dimensions of Ao arch. Aortic valve and left ventricle. Hemodynamics: Pressure gradient estimation. Collateral flow. Flow profile analysis. Post-intervention complications.
MR Flow Pressure Gradient Peak velocity = 2.3 cm/s Pressure Gradient = 21 mmhg Magnitude Phase Peak velocity = 2.9 cm/s Pressure Gradient = 33 mmhg
MR Flow Collateral Flow Hope MD et al. Chpt 17. In Ho and Reddy (Eds), Cardiovasc Imaging, Elsevier Inc.
MR Flow Collateral Flow
MR Flow Collateral Flow Steffens JC et al. Circulation 1994
Pujadas S et al. JRMI 2006 Coarctation MR Flow Collateral Flow
MR Flow Aliasing High VENC Low VENC Hope MD et al. Chpt 17. In Ho and Reddy (Eds), Cardiovasc Imaging, Elsevier Inc.
MR Flow Aliasing Low VENC Higher VENC
Hope MD et al. JRMI 2010 Coarctation 4D Flow Collateral Flow
MR Flow 2D vs 4D Collateral Flow Correlation Coefficient = 0.96 Hope MD et al. JRMI 2010
Courtesy of S. Muzzarelli Coarctation MR Flow Aortic Flow Profiles
Courtesy of S. Muzzarelli Coarctation MR Flow Aortic Flow Profiles
1 Background 2 Imaging - Morphology 3 Imaging - Hemodynamics 4 Associations and Complications
Associations Cardiac defects (50%): PDA VSD LVOT obstruction BAV Arch hypoplasia Extracardiac: Berry aneurysms of Circle of Willis Turner syndrome
Associations - BAV Very common (up to 85%). Valvular dz > half. Many develop heart failure. Aneurysm and dissection. Frequent surveillance.
Associations - Turners Bondy CA. Curr Opin Cardiol 2008
Complications - Pregnancy Even if repaired: Increased risk of Ao Dissection. Cerebral aneurysm rupture. Caution if Ao dilation. Significant stenosis is contraindication.
Coartation Repair Complications - Psuedoaneurysm Dacron Patch Repair Shih MC et al. AJR 2006
Coartation Repair Complications - Aneurysm
Coartation Repair Complications - Psuedoaneurysm Frydrychowicz A, Markl M et al. JCMR 2008
Coartation Repair Complications - Psuedoaneurysm Hope et al. Circulation: CV Imaging 2010 (pending)
Hope et al. Radiology 2010 The End