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Evaluation of a comprehensive cardiovascular magnetic resonance protocol in young adults late after the arterial switch operation for d-transposition of the great arteries.

Tobler D, Motwani M, Wald RM, Roche SL, Verocai F, Iwanochko RM, Greenwood JP, Oechslin EN, Crean AM - J Cardiovasc Magn Reson (2014)

Bottom Line: In 24 cases the coronary ostia could conclusively be demonstrated to be normal.The data shows that the asymptomatic and clinically stable adult ASO patient has a low pre-test probability for inducible ischemia.In this situation it is likely that routine evaluation with stress CMR is unnecessary.

View Article: PubMed Central - PubMed

Affiliation: Toronto Congenital Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto General Hospital, 585 University Avenue, 5 N-525, Toronto M5G 2N2, ON, Canada. andrew.crean@uhn.ca.

ABSTRACT

Background: In adults with prior arterial switch operation (ASO) for d-transposition of the great arteries, the need for routine coronary artery assessment and evaluation for silent myocardial ischemia is not well defined. In this observational study we aimed to determine the value of a comprehensive cardiovascular magnetic resonance (CMR) protocol for the detection of coronary problems in adults with prior ASO for d-transposition of the great arteries.

Methods: Adult ASO patients (≥18 years of age) were recruited consecutively. Patients underwent a comprehensive stress perfusion CMR protocol that included measurement of biventricular systolic function, myocardial scar burden, coronary ostial assessment and myocardial perfusion during vasodilator stress by perfusion CMR. Single photon emission computed tomography (SPECT) was performed on the same day as a confirmatory second imaging modality. Stress studies were visually assessed for perfusion defects (qualitative analysis). Additionally, myocardial blood flow was quantitatively analysed from mid-ventricular perfusion CMR images. In unclear cases, CT coronary angiography or conventional angiography was done.

Results: Twenty-seven adult ASO patients (mean age 23 years, 85% male, 67% with a usual coronary pattern; none with a prior coronary artery complication) were included in the study. CMR stress perfusion was normal in all 27 patients with no evidence of inducible perfusion defects. In 24 cases the coronary ostia could conclusively be demonstrated to be normal. There was disagreement between CMR and SPECT for visually-assessed perfusion defects in 54% of patients with most disagreement due to false positive SPECT.

Conclusions: Adult ASO survivors in this study had no CMR evidence of myocardial ischemia, scar or coronary ostial abnormality. Compared to SPECT, CMR provides additional valuable information about the coronary artery anatomy. The data shows that the asymptomatic and clinically stable adult ASO patient has a low pre-test probability for inducible ischemia. In this situation it is likely that routine evaluation with stress CMR is unnecessary.

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Related in: MedlinePlus

Bilateral pulmonary artery stents obscuring coronary origins at CMR. (A, B) Metallic artifact from bilateral pulmonary artery (PA) stents (arrows) on steady state free precession cine imaging obscures the coronary arteries as they emerge from the neo-aortic root. (C) Multiplanar reformat from low dose cardiac gated computed tomography reveals normal origins of the right coronary artery (solid arrow), left anterior descending (dashed arrow) and circumflex (dotted arrow) coronary arteries. (D) Lack of effect of bilateral PA stents (arrows) on visibility of the coronary arteries at cardiac CT is apparent on this coronal reformat. RV = right ventricle; LV = left ventricle; nAo = neo aorta.
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Fig5: Bilateral pulmonary artery stents obscuring coronary origins at CMR. (A, B) Metallic artifact from bilateral pulmonary artery (PA) stents (arrows) on steady state free precession cine imaging obscures the coronary arteries as they emerge from the neo-aortic root. (C) Multiplanar reformat from low dose cardiac gated computed tomography reveals normal origins of the right coronary artery (solid arrow), left anterior descending (dashed arrow) and circumflex (dotted arrow) coronary arteries. (D) Lack of effect of bilateral PA stents (arrows) on visibility of the coronary arteries at cardiac CT is apparent on this coronal reformat. RV = right ventricle; LV = left ventricle; nAo = neo aorta.

Mentions: In the third case (Patient 11), the ostia were unevaluable due to the presence of bilateral pulmonary artery stents (Figure 5); visual and quantitative CMR perfusion and SPECT were all normal and the subsequent coronary CT was unremarkable.Figure 5


Evaluation of a comprehensive cardiovascular magnetic resonance protocol in young adults late after the arterial switch operation for d-transposition of the great arteries.

Tobler D, Motwani M, Wald RM, Roche SL, Verocai F, Iwanochko RM, Greenwood JP, Oechslin EN, Crean AM - J Cardiovasc Magn Reson (2014)

Bilateral pulmonary artery stents obscuring coronary origins at CMR. (A, B) Metallic artifact from bilateral pulmonary artery (PA) stents (arrows) on steady state free precession cine imaging obscures the coronary arteries as they emerge from the neo-aortic root. (C) Multiplanar reformat from low dose cardiac gated computed tomography reveals normal origins of the right coronary artery (solid arrow), left anterior descending (dashed arrow) and circumflex (dotted arrow) coronary arteries. (D) Lack of effect of bilateral PA stents (arrows) on visibility of the coronary arteries at cardiac CT is apparent on this coronal reformat. RV = right ventricle; LV = left ventricle; nAo = neo aorta.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4263214&req=5

Fig5: Bilateral pulmonary artery stents obscuring coronary origins at CMR. (A, B) Metallic artifact from bilateral pulmonary artery (PA) stents (arrows) on steady state free precession cine imaging obscures the coronary arteries as they emerge from the neo-aortic root. (C) Multiplanar reformat from low dose cardiac gated computed tomography reveals normal origins of the right coronary artery (solid arrow), left anterior descending (dashed arrow) and circumflex (dotted arrow) coronary arteries. (D) Lack of effect of bilateral PA stents (arrows) on visibility of the coronary arteries at cardiac CT is apparent on this coronal reformat. RV = right ventricle; LV = left ventricle; nAo = neo aorta.
Mentions: In the third case (Patient 11), the ostia were unevaluable due to the presence of bilateral pulmonary artery stents (Figure 5); visual and quantitative CMR perfusion and SPECT were all normal and the subsequent coronary CT was unremarkable.Figure 5

Bottom Line: In 24 cases the coronary ostia could conclusively be demonstrated to be normal.The data shows that the asymptomatic and clinically stable adult ASO patient has a low pre-test probability for inducible ischemia.In this situation it is likely that routine evaluation with stress CMR is unnecessary.

View Article: PubMed Central - PubMed

Affiliation: Toronto Congenital Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto General Hospital, 585 University Avenue, 5 N-525, Toronto M5G 2N2, ON, Canada. andrew.crean@uhn.ca.

ABSTRACT

Background: In adults with prior arterial switch operation (ASO) for d-transposition of the great arteries, the need for routine coronary artery assessment and evaluation for silent myocardial ischemia is not well defined. In this observational study we aimed to determine the value of a comprehensive cardiovascular magnetic resonance (CMR) protocol for the detection of coronary problems in adults with prior ASO for d-transposition of the great arteries.

Methods: Adult ASO patients (≥18 years of age) were recruited consecutively. Patients underwent a comprehensive stress perfusion CMR protocol that included measurement of biventricular systolic function, myocardial scar burden, coronary ostial assessment and myocardial perfusion during vasodilator stress by perfusion CMR. Single photon emission computed tomography (SPECT) was performed on the same day as a confirmatory second imaging modality. Stress studies were visually assessed for perfusion defects (qualitative analysis). Additionally, myocardial blood flow was quantitatively analysed from mid-ventricular perfusion CMR images. In unclear cases, CT coronary angiography or conventional angiography was done.

Results: Twenty-seven adult ASO patients (mean age 23 years, 85% male, 67% with a usual coronary pattern; none with a prior coronary artery complication) were included in the study. CMR stress perfusion was normal in all 27 patients with no evidence of inducible perfusion defects. In 24 cases the coronary ostia could conclusively be demonstrated to be normal. There was disagreement between CMR and SPECT for visually-assessed perfusion defects in 54% of patients with most disagreement due to false positive SPECT.

Conclusions: Adult ASO survivors in this study had no CMR evidence of myocardial ischemia, scar or coronary ostial abnormality. Compared to SPECT, CMR provides additional valuable information about the coronary artery anatomy. The data shows that the asymptomatic and clinically stable adult ASO patient has a low pre-test probability for inducible ischemia. In this situation it is likely that routine evaluation with stress CMR is unnecessary.

Show MeSH
Related in: MedlinePlus