docImaging and Management of Adults with Coarctation and Aortic Arch
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Imaging and Management of Adults with Coarctation and Aortic Arch
Aortic Coarctation Imaging and Management in Adults Michael D. Hope, MD 1 Background 2 Imaging - Morphology 3 Imaging - Hemodynamics 4 Associations and Complications Coarctation Presurgical Era Campbell M. British Heart Journal 1970 Coarctation Presurgical Era If coexisting BAV, 50% died of aortic dissection/rupture. Abbott ME. Am Heart Journal 1928 Campbell M. British Heart Journal 1970 Coarctation “Correctable Lesion” Surgical repair 1st 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. 2. 3. 4. 5. End-to-end Subclav aortoplasty Patch aortoplasy Interposition graft Bypass graft Ming-Chen et al. AJR 2005 Coarctation 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. Coarctation Post Op Complications Jenkins NP, Ward C QJM 1999 1 Background 2 Imaging - Morphology 3 Imaging - Hemodynamics 4 Associations and Complications Coarctation Imaging Echocardiography CT MRI Coarctation 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. Coarctation MR Imaging - MRA Coarctation MR Imaging - MRA MIP Subvolume MIP 3D Volume Rendering Coarctation MRI - Black Blood Oblique Sag SE MRA Coarctation MRI - Black Blood with Stent Coarctation MRA – Arch Geometry Gothic Ou P. et al. European Heart Journal 2004 Crenel Normal Coarctation MRA - Aortic Ratio < 0.9 hypoplasia, assoc w/ aneurysm at repair site > 1.5 high risk for progressive aneurysmal dilation Coarctation MRI - Aortic Valve Morphology Coarctation MRI - Left Ventricular Hypertrophy 1 Background 2 Imaging - Morphology 3 Imaging - Hemodynamics 4 Associations and Complications Coarctation 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. Coarctation 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 Coarctation MR Flow – Collateral Flow Hope MD et al. Chpt 17. In Ho and Reddy (Eds), Cardiovasc Imaging, Elsevier Inc. Coarctation MR Flow – Collateral Flow Coarctation MR Flow – Collateral Flow Steffens JC et al. Circulation 1994 Coarctation MR Flow – Collateral Flow Pujadas S et al. JRMI 2006 Coarctation MR Flow – Aliasing High VENC Low VENC Hope MD et al. Chpt 17. In Ho and Reddy (Eds), Cardiovasc Imaging, Elsevier Inc. Coarctation MR Flow – Aliasing Low VENC Higher VENC Coarctation 4D Flow – Collateral Flow Hope MD et al. JRMI 2010 Coarctation MR Flow – 2D vs 4D Collateral Flow Correlation Coefficient = 0.96 Hope MD et al. JRMI 2010 Coarctation MR Flow – Aortic Flow Profiles Courtesy of S. Muzzarelli Coarctation MR Flow – Aortic Flow Profiles Courtesy of S. Muzzarelli 1 Background 2 Imaging - Morphology 3 Imaging - Hemodynamics 4 Associations and Complications Coarctation Associations Cardiac defects (50%): • • • • • PDA VSD LVOT obstruction BAV Arch hypoplasia Extracardiac: • • Berry aneurysms of Circle of Willis Turner syndrome Coarctation Associations - BAV Very common (up to 85%). Valvular dz > half. Many develop heart failure. Aneurysm and dissection. Frequent surveillance. Coarctation Associations - Turners Bondy CA. Curr Opin Cardiol 2008 Coarctation 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) The End Hope et al. Radiology 2010
