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Studio del cuore con rm fetale Manganaro


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  • 1. STUDIO DEL CUORE CON RM FETALE Lucia Manganaro Dipartimento di Scienze Radiologiche Oncologiche e antamopatologiche
  • 2. BACKGROUND  Congenital heart disease is one of the most frequent prenatal malformations (incidence of 5/1000 live births),it represents the primary cause of death in the first year of life  Considering the wide range of severity, a good prenatal examination acquires a great importance in order to formulate an early diagnosis and improve the pregnancy management  Nowadays investigation of CHD is performed with echocardiography considered the standard reference for diagnosis
  • 3.  Various studies demonstrated the potential role of fetal magnetic resonance imaging as an adjunctive imaging technique in the prenatal evaluation of CHD.  MRI may add other clinical information regarding associated extracardiac pathologies *  MRI could be advisable from the second trimester of pregnancy, when a preliminary ultrasound examination proves inadequate or diagnostically inconclusive *  MRI could offer a better imaging compared to US in an advanced gestational stage because of the progressive reduction of amniotic fluid and the ribs ossification * Manganaro L; Savelli S; Di Maurizio M et al. Assessment of congenital heart disease (CHD): Is there a role for fetal magnetic resonance imaging (MRI)?. European Journal of Radiology 72 (2009) 172-180. Role of fetal MRI
  • 4. KEY POINTS  Techniques  Anatomical considerations  Classification  Discussion  Conclusions
  • 5. STANDARD PROTOCOL OF STUDY  Localization sequence : T2-weighted half-Fourier single-shot turbo spin-echo sequence (HASTE)(TR 1,000, TE 118/151, matrix 256×134, slice thickness 6 mm, FOV 27×20 cm) acquired in the coronal plane to evaluate fetal lie.  Anatomical study: T2 weighted HASTE sequences with a slice thickness of 3-4 mm, performed on a multiplanar orientation.  Static phase of study: ultrafast gradient-echo (GRE) sequences with SSFP, known as fast imaging with steady-state free precession (True-FISP)( TR/TE 3.5/1.5, matrix 256×144, slice thickness 3–4 mm, FOV 40×30 cm), oriented in the three planes of the space  Dynamic phase of study : real-time cine MRI True-FISP 2D sequences, known as TF2D on Magnetom Avanto (TR/TE 248.5/1.1, matrix 192×99, slice thickness 3–4 mm, FOV 38×26 cm, FA 77°, temporal resolution two slices/s), repeated dynamically (40 times) MRI examination takes between 20 and 45 minutes depending on the movement of the fetus 1.5-T MR unit system, phased body coil (Siemens Magnetom Avanto, Erlangen,Germany).
  • 6.  suboptimal anatomical visualization of all the fetus body, in particular of static fluid  fast acquisition time  low ratio rumors-signal enables the avoidance of holding mother’s breath  highly sensitive to flow, heart and blood-filled vessels are visualised as a lack of signal T2 HASTE sequences
  • 7. True-FISP (fast imaging with steady-state free precession) sequences  Are not influenced by movement  highlight structures wirh fluid in motion showing high signal intensity  both static and motion fluid are visualised with elevated signal  The short echo time allows a good evaluation of the myocardial thickness and interventricular septum thanks to the higher contrast resolution blood-tissue on endocardium * * Gorincour G, Bourliè Re-Najean B, Bonello B et al. Feasibility of fetal cardiac magnetic resonance imaging: preliminary experience. Ultrasound Obstet Gynecol 2007; 29: 105–110
  • 8.  suboptimal visualization of the cardiac movement  effective evidentation of the morphological features  impossibility of fetal cardiac triggering Real-time cine MRI True-FISP 2D sequences
  • 9. NEW PROSPECTIVES Gradient Echo T1 w 3D Angiography like sequence: Technical parameters: TR: 25 TE: 8.4 Flip angle: 10 FOV: 17.7 cm x 29.9 cm Matrice: 256 x 192 Slice thickness: 4.00 Distance factor: 50% TA: 40s
  • 10.  TRANSVERSAL VIEWS: - Four chambers - Five chambers - Three vessels  SAGITTAL VIEWS: - Short axis left ventricle - Tricuspid-aortic cut - Long axis of the ductus arteriosus - Long axis of the aortic arch  ANGULATED VIEWS: - Long axis of the left ventricle - Aortic arch and ductus arteriosus Projection
  • 11.  T2 HASTE sequences evaluate fetal lie (longitudinal, transverse, oblique), presentation (cephalic, breech, shoulder), and anatomical details  True-FISP sequences allow the highlighting of the cardial apex orientation and the cardial situs ANATOMICAL CONSIDERATIONS
  • 14.  Four chamber view - heart size and orientation - cardiac apex position - ventricular septum angulation - dimension of cardiac chambers - integrity of ventricular and atrial septum Anatomy 1 RV RA LA LV
  • 15.  Five chamber view - aorta arising from the left ventricle in the center of the heart Anatomy 2
  • 16.  Three vessels view: - size and position of pulmonary artery (PA), aorta (Ao) and of superior vena cava (SVC)  Aortic arch view: - aortic arch and SVC Anatomy 2
  • 17.  Short axis of the left ventricle: - right ventricle shape - left ventricle shape - position of both ventricles  Tricuspid-Aortic view: - right chambers position - IVC and SVC outflow - aortic outflow Anatomy 4
  • 18.  Long axis of the ductus arteriosus : - origin of pulmonary artery that connects to the Ao via the ductus, forming a ductal arch Anatomy 5
  • 19.  Long axis of the left ventricle: - origin of the Aorta from left ventricle in the center of the heart Anatomy 6
  • 20. Anatomy 7  Aortic arch and ductus arteriosus view - Simultaneous view of aortic arch and ducrus - Same size of two vessels
  • 21. CINE-MR videos
  • 22.  Fetal MRI study is based on the analisis of both direct and indirect signs of pathology DIRECT SIGNS INDIRECT SIGNS  cardial situs  cardiothoracic index  anomalies of the volume and conformation of chambers and myocardial  malrotation of the cardiac axis  septal defects  vessel’s pathologies anomalies of the origin, size and course of the great arteries  absence of anatomical structures  increased size of vessel before a stenotic region hypertrophy of the papillary muscles  presence of cardiomegaly  pericardial effusion Detection of CHD
  • 23.  To simplify the understanding of CHD we identify 7 categories: 1. cardial situs anomalies 2. right and left ventricular hypoplasia 3. cardiac masses 4. great vessel abnormalities 5. abnormalities of transposition and connection 6. defects of inflow and outflow 7. septal defects Characterization of CHD
  • 24. a c d  Situs inversus is easy to recognize after a first valuation of the position of the fetus compared to the mother in order to define the left and right sides. Moreover fetal MRI allows assessment of the visceroatrial situs in relation to the bronchi. The fluid-filled bronchial tree appears as high-signal- intensity structures on SSFP images *. *Brugger PC, Stuhr F, Linder C, Prayer D. Methods of fetal MR: beyond T2-weighted imaging. Eur J Radiol2006 1.Cardial situs anomalies b 27-week gestation fetus with complete situs inversus. Fetus position is transversal with head on the right side of the mother as indicated by the position of the liver( white arrow) and stomach (red arrow) Figure a) represent the posterior plan of the coronal view acquired on the mother, it shows the liver (arrow) instead of the stomach, which is endeed shown on an anterior plane of the coronal view ( figure b). c)Liver is located on the left side of the fetus. d) heart is located on the right side.
  • 25.  Right ventricular hypoplasia: reduction of the right ventricular cavity with thick walls (three vessels view)  Left ventricle hypoplasia: mitral and aortic atresia, both left chambers appear reduced with virtual cavity,the apex is composed of the right ventricle 2.Hypoplasia 32-week gestational age fetus with hypoplastic left heart syndrome. a) hypertrophic right ventricle ,right ventricle occupies the aepex of the heart a b 26-week gestational age fetus with hypoplastic lright heart syndrome. a) hypertrophic left ventricle
  • 26.  Rhabdomyomas : • most frequent prenatal tumors, • usually associated with tuberous sclerosis • frequently distributed in the left ventricle (move simultaneously with ventricles) • appear hypointense in T2 weighted sequences and hyperintense in T1 weighted sequences • it’s required the study of the brain 3.Cardiac masses 1 33-week gestational age fetus affected by tuberous sclerosis,a) nodular hypointense lesion (arrow) located in the right ventricle. b-c) subependymal rhabdomyoma located next to the lateral ventricle (arrows)
  • 27. 3. Cardiac masses ?
  • 28.  Teratomas: • inhomogeneous in T2 weighted sequences for the combination of solid and fluid components • differential diagnosis with thorax pathologies (ex: CCAM , BPS) 3.Cardiac masses 2 25 week gestation fetus affected by perycardial teratoma. Multilobulated lesion with inhomogeneous signal in T2w sequences (arrow), located in the perycardium.
  • 29. Aortic coartaction (CoA): reduction of the left ventricle; There is considerable overlap in the relative size of the aortic arch, therefore a diagnosis of coartaction is generally a provisional diagnosis even in echocardioghraphy. preliminary experiences demonstrated how measurement, on the three vessel view, of the main mediastinal pulmonary artery to ascending Ao diameter ratio can be a helpful tool in distinguishing true CoA[-] Slodki M, Rychik J, Moszura et Al.Measurement of the great vessels in the mediastinum could help distinguish true from false-positive coarctation of the aorta in the third trimester.J Ultrasound Med. 2009 Oct;28(10):1313-7. . 4.Great vessels abnormalities 32 week gestation fetus affected by aortic coartaction (arrows). a-b) Gradient Echo T1 weighted 3D sequences a b c
  • 30. 4.Great vessels abnormalities2  Aortic corctation 2: 28-week gestation fetus. a)vessel view (arrow) b)hypoplastic left ventricle (arrow) c)aortic coartaction (arrowhead)  Aortic corctation 3: 27-week gestation fetus with DiGeorge syndrome. Both axial scans illustrate the aortic coartaction (long arrow) and the thymus absence (short arrow) . a b c
  • 31.  Transposition: aorta arises form the right ventricle and the pulmonary artery from the left ventricle, commonly associated to concordant atrio ventricular connection. 5.Abnormalities of great artery position and connection 1 Ao Ao RA AP LA Ao RV RA IVC SVC 33-week gestational age fetus with complete transposition of the great vessels. Aorta (Ao) arising from the right ventricle (RV), in a heart with concordant atrioventricular connections.
  • 32.  Double outlet right ventricle: both great arteries arise mainly from the right ventricle. Signs of the pathology are the disproportion of ventricles, the arteries position and origins. Aorta and pulmonary artery show a parallel orientation 5.Abnormalities of great artery position and connection 2 Both great arteries Ao (*) and PA (arrow) arise from right ventricle, and show parallel orentation
  • 33.  Fallot tetralogy: aorta exiting the heart overriding ventricles, myocardial hyperthrophy, interventricular septal defects caused by wrong alignment 5.Abnormalities of great artery position and connection 3 38-week gestational age fetus with Fallot tetralogy. Aorta exiting the heart overriding ventricles (arrows)
  • 34.  Common arterial trunk: only one artery arising from the heart, which gives rise to aorta and pulmonary artery; right position of the aorta, the possible interruption or agenesis of the aorta, the absence or stenosis of the arterial duct 5.Abnormalities of great artery position and connection 4 33-week gesttional fetus with common arterial trunk, unique artery (arrows) which gives rises to aorta and pulmonary artery (arrow-head)
  • 35. 5.Abnormalities of great artery position and connection 5 Azygos continuation
  • 36.  Outflow defects: obstructive left outflow: disproportion of the left and right chambers with the possibility of a wider right ventricle obstructive right outflow: enlargement of the right ventricle, associated to a right atrial enlargement and myocardial thickness.  Inflow defects: mitral stenosis or valves deficiency 6. Outflow and Inflow defects 30° week gestation fetus affected by obstructive right outflow (tricuspidal atresia). Severe reduction of the right ventricle with virtual lumen (arrow) and right atrium dilatation (*). B) absente visualization of pulmonary outflow
  • 39.  Septal atrial defects: secundum atrial septal defect, difficult to diagnose because of the physiological persistence of the foramen ovale. In wide defects indirect signs such as an enlargement of the right atrium can be associated.  Septal ventricular defects: well studied in the four chamber views, often associated with other pathologies such as a Fallot syndrome. 7.Septal defects 1 32-week gestational age fetus with septal ventricle defect. Lack of continuity in the lower septal part (arrow) 27-weekgestational fetu swith wide septal artial defect, absence of the atrial sepum (arrow) in a four chamber view.
  • 40.  Common atrioventricular septal defect: associated with a deficiency in the central septal , a unique central valve and a defect of the ventricular septum which appear to unevenly divide the heart (unbalanced ventricles) More difficult is the diagnosis of partial atrioventricular septal defect characterized by only the atrial defect. 7.Septal defects 2 a) Wide septal atrial and ventricular defect . b) malrotation of the cardiac axis
  • 41. 29-weeks fetus - VENTRICULAR SEPTAL DEFECT (VSD) with possible association of coartaction of the aorta excluded by angio-MR sequences T1 3D SPOILED GE angio-MR sequences to assess the aorta (MIP)
  • 42.  Lungs  Thymus Other malformations (BRAIN)
  • 43.  Studies with heterogenus and small population  Absence of standardized measurement and protocols  Technical and Anatomical Limitations :  Severe heart malrotation  Small heart size  Low evaluation of motion fluid  Absence of real time resolution due to: - Fast fetal heart rate - Low time resolution - Impossibility of cardiac triggering LIMITS OF CARDIOVASCULAR MRI  Inability to study : - valvular disease (indirect signs) - rhythm disorders
  • 44. FETAL MRI ALLOWS:  Anatomical characterization of the fetal heart: TrueFISP sequences  Suboptimal dynamic evaluation of cardiac function: Real-time Cine-RM sequences According to the preliminary experiences, other studies with significantly large population may offer a standardization of the MRI examination. CONCLUSIONS 1
  • 45.  Nowadays few studies indicate that indications to fetal MRI include inconclusive US examination* or coexistence of extracardial associated pathologies  However in literature it is demonstrated that MRI may be used as an adjunctive imaging technique associated to echocardiography in order to confirm and better define the diagnosis CONCLUSIONS 2 * Saleem SN. Feasibility of MRI of the Fetal Heart with Balanced Steady-State Free Precession Sequence Along Fetal Body and Cardiac Planes. AJR 2008; 191: 1208-1215
  • 46. FETAL MRI The development of new dynamic sequences may contribute to expand the role of fetal MRI; moreover the development of angiography-sequences may be helpful to visualize fetal vascular in 2D or 3D * making it an indispensable tool in the study of the fetal heart, in order to obtain a precise prenatal diagnosis and a better delivery management. *Baker E.. What’s new in magnetic resonance imaging? CardiolYoung 2001.11: 445–452 CONCLUSIONS 3
  • 47. - Dott.ssa V. Vinci - Dott.ssa A. Tomei - Dott.ssa F. Fierro - Dott. P. Sollazzo - Dott.ssa D. Irimia - Dott. ssa E. Sergi --Dott.ssa S. Bernardo Lucia Manganaro Department of Radiological Sciences Policlinico Umberto I Hospital, “Sapienza” University of Rome