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RM
UTILITA’ e LIMITI
Lucia Manganaro
Dipartimento di Scienze Radiologiche
Oncologiche e antamopatologiche
AGGI ORNAMENTI D...
BACKGROUND
 Congenital heart disease is one of the most frequent prenatal
malformations (incidence of 5/1000 live births)...
 TRANSVERSAL VIEWS: - Four chambers
- Five chambers
- Three vessels
 SAGITTAL VIEWS: - Short axis left ventricle
- Tricu...
 To simplify the understanding of CHD we identify
7 categories:
1. cardial situs anomalies
2. right and left ventricular ...
a
c
d
 Situs inversus is easy to recognize after a first valuation of the position of
the fetus compared to the mother in...
 Right ventricular
hypoplasia:
reduction of the right
ventricular cavity with thick
walls (three vessels view)
 Left ven...
3. Cardiac masses
?
 Teratomas:
• inhomogeneous in T2 weighted
sequences for the combination of
solid and fluid components
• differential dia...
Aortic coartaction (CoA): reduction of the left ventricle; There is considerable overlap in the relative size of
the aorti...
4.Great vessels abnormalities2
 Aortic corctation 2:
28-week gestation
fetus.
a)vessel view (arrow)
b)hypoplastic left
ve...
 Transposition:
aorta arises form the right ventricle and the pulmonary artery from the left
ventricle, commonly associat...
 Double outlet right ventricle:
both great arteries arise mainly from the right ventricle. Signs of the
pathology are the...
 Fallot tetralogy:
aorta exiting the heart overriding ventricles, myocardial hyperthrophy,
interventricular septal defect...
 Common arterial trunk:
only one artery arising from the heart, which gives rise to aorta and
pulmonary artery; right pos...
5.Abnormalities of great artery
position and connection 5
Azygos
continuation
Double aortic arch
5.Abnormalities of great artery position and
connection 6
 Outflow defects:
obstructive left outflow:
disproportion of the left and right
chambers with the possibility of a
wider ...
DIV
PULMONARY
ATRESIA
DIV
27 Week
AP?
SVC
AO
AO
SVC
AO
PULMONARY ATRESIA
32° WEEK
 Septal atrial defects:
secundum atrial septal defect,
difficult to diagnose because of
the physiological persistence of
...
 Common atrioventricular
septal defect:
associated with a deficiency in
the central septal , a unique
central valve and a...
29-weeks fetus - VENTRICULAR SEPTAL DEFECT
(VSD) with possible association of coartaction of the
aorta excluded by angio-M...
 Various studies demonstrated the potential role of fetal magnetic resonance imaging
as an adjunctive imaging technique i...
 Various studies demonstrated the potential role of fetal magnetic resonance imaging
as an adjunctive imaging technique i...
 Lungs
 Thymus
Other malformations (BRAIN)
 Rhabdomyomas :
• most frequent prenatal tumors,
• usually associated with tuberous sclerosis
• frequently distributed in...
ROLE OF FETAL MRI
 Postmortem cardiac imaging in fetuses
3-D cardiac postmortem MRI
MARIAS (magnetic resonance imaging au...
 Complete atrioventricular
septal defect (dotted line)
on axial T2-weighted
postmortem MRI in a 22-
week gestation fetus ...
 Fetal cardiac postmortem
MRI in a 29-week gestation fetus
shows a large cardiac teratoma (T)
following unsuccessful in u...
 Fetal cardiac postmortem MRI shows
hypoplastic left heart syndrome
on sagittal T2-weighted image in a 22-
week gestation...
Three-dimensional cardiac postmortem MRI can provide
equivalent structural information to that of conventional autopsy
in ...
 Studies with heterogenus and small population
 Absence of standardized measurement and protocols
 Technical and Anatom...
FETAL CARDIAC MRI
FETAL CARDIAC MRI
 3D MRI SEQUENCES
 Higher SNR
 Ability to reformat images in muliple planes
Fast free –breathing in v...
FETAL CARDIAC MRI
 More sensitive to fetal motion
FETAL MRI
 Although advances in magnetic resonance technology have expanded the clinical role of MRI
for pediatric patien...
Lucia Manganaro
Department of Radiological Sciences
Policlinico Umberto I Hospital, “Sapienza” University of Rome
lucia.ma...
20 l manganaro rm fetale utilita’ e limiti
20 l manganaro rm fetale utilita’ e limiti
20 l manganaro rm fetale utilita’ e limiti
20 l manganaro rm fetale utilita’ e limiti
20 l manganaro rm fetale utilita’ e limiti
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20 l manganaro rm fetale utilita’ e limiti

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20 l manganaro rm fetale utilita’ e limiti

  1. 1. RM UTILITA’ e LIMITI Lucia Manganaro Dipartimento di Scienze Radiologiche Oncologiche e antamopatologiche AGGI ORNAMENTI DI ECOCARDI OGRAFI A FETALE I I a edizione S Dipartimento di Pediatria Policlinico Umberto I Università “Sapienza” Roma 18/ 19 Aprile 2015
  2. 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. 3.  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
  4. 4.  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
  5. 5. 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.
  6. 6.  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
  7. 7. 3. Cardiac masses ?
  8. 8.  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.
  9. 9. 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
  10. 10. 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
  11. 11.  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.
  12. 12.  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
  13. 13.  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)
  14. 14.  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)
  15. 15. 5.Abnormalities of great artery position and connection 5 Azygos continuation
  16. 16. Double aortic arch 5.Abnormalities of great artery position and connection 6
  17. 17.  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
  18. 18. DIV PULMONARY ATRESIA DIV 27 Week AP? SVC AO AO SVC AO
  19. 19. PULMONARY ATRESIA 32° WEEK
  20. 20.  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.
  21. 21.  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
  22. 22. 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)
  23. 23.  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 ROLE OF FETAL MRI
  24. 24.  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 ROLE OF FETAL MRI
  25. 25.  Lungs  Thymus Other malformations (BRAIN)
  26. 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 Cardiac masses 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. 27. ROLE OF FETAL MRI  Postmortem cardiac imaging in fetuses 3-D cardiac postmortem MRI MARIAS (magnetic resonance imaging autopsy study) compared the diagnostic accuracy of 3-D cardiac postmortem MRI with conventional autopsy and histopathology assessment in fetuses and children
  28. 28.  Complete atrioventricular septal defect (dotted line) on axial T2-weighted postmortem MRI in a 22- week gestation fetus with trisomy 21. Note air in the right ventricle (RV) secondary to fetocide injection and a trace of pericardial effusion. LV left ventricle
  29. 29.  Fetal cardiac postmortem MRI in a 29-week gestation fetus shows a large cardiac teratoma (T) following unsuccessful in utero laser ablation. The large teratoma displaces the heart posteriorly and laterally on (a) axial and (b) oblique coronal T2-weighted images. LV left ventricle, Rvrig ventricle
  30. 30.  Fetal cardiac postmortem MRI shows hypoplastic left heart syndrome on sagittal T2-weighted image in a 22- week gestation fetus. LV left ventricle, RV right ventricle.
  31. 31. Three-dimensional cardiac postmortem MRI can provide equivalent structural information to that of conventional autopsy in the majority of larger fetuses, newborns and children. This technique may have a major role in developing lessinvasive autopsy methods. Moreover, routine use of cardiac postmortem MRI as an adjuvant to conventional autopsy may increase the yield from conventional autopsy. Further study of high-field postmortem MRI, postmortem CT and micro-CT will continue to optimize the best methods for this form of less-invasive postmortem assessment.
  32. 32.  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 - cardiac triggering LIMITS OF CARDIOVASCULAR MRI  Inability to study : - valvular disease (indirect signs) - rhythm disorders
  33. 33. FETAL CARDIAC MRI
  34. 34. FETAL CARDIAC MRI  3D MRI SEQUENCES  Higher SNR  Ability to reformat images in muliple planes Fast free –breathing in vivo fetal imaging using time-resolved 3D-MRI technique: preliminary results Liu J et al . Quant Imaging Med Surg 2014
  35. 35. FETAL CARDIAC MRI  More sensitive to fetal motion
  36. 36. FETAL MRI  Although advances in magnetic resonance technology have expanded the clinical role of MRI for pediatric patients with CHD, the application of MRI to the fetal heart has been limited because of the small size of fetal cardiac structures, random fetal motion, and the challenge of gating the rapidly beating fetal heart in the absence of a fetal electrocardiogram. Furthermore, in contrast to conventional ultrasound technology, MRI requires expensive, large, less portable equipment, as well as specialized expertise to perform and interpret. Nevertheless, MRI offers several advantages over obstetric ultrasound. Fetal position, rib calcification, maternal obesity, and oligohydramnios, particularly during the third trimester, interfere more with ultrasound imaging than with MRI. If the challenges relating to motion and cardiac gating can be overcome, MRI has the potential to provide high-resolution imaging of the fetal heart in multiple planes and to generate volume data sets with greater resolution than those obtained with ultrasound, offering the potential to provide robust quantitative evaluation of cardiac function and chamber volumes and to provide unique perspectives on venous and arterial anatomy, visceroatrial situs, and thoracic extracardiac malformations affecting fetal cardiovascular structure/function.
  37. 37. Lucia Manganaro Department of Radiological Sciences Policlinico Umberto I Hospital, “Sapienza” University of Rome lucia.manganaro@uniroma1.it

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