Review of new techniques in echocardiography and magnetic resonance imaging as applied to patients with congenital heart disease

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Figure 1  .

7.5 MHz high resolution intraoperative transoesophageal echocardiography (TOE) images of a subaortic ventricular septal defect with aortic valve prolapse using an 8 mm micromultiplane TOE probe developed with National Institutes of Health funding from grant 1R01 HL 36472-01.¹

Figure 2  .

Improved resolution for transabdominal imaging of the fetal heart obtained in a 24 week fetus imaged on the four chamber view using a method combining compound scanning with a 5 MHz curved array (Sono CT, ATL Ultrasound) and a pulse conversion tissue harmonic method.

Figure 3  .

A gated, rotational acquisition digital three dimensional method for automatically computing stroke volume from flow rates computed from digital Doppler data scanned parallel to the direction of flow but analysed on a Gaussian surface perpendicular to the scan lines in the image in an in vitro tapered vessel model.³

Figure 4  .

Multiplanar right ventricular views derived from real time three dimensional echo in a chronic animal model of pulmonary regurgitation.⁴

Figure 5  .

Rotational three dimensional reconstruction image of the left ventricle with encoded longitudinal tissue Doppler imaging values in a patient with inferior wall (yellow and trace) hypokinesis.

Figure 6  .

Tissue and colour Doppler images of left to right ductal flow in a newborn infant with pulmonary atresia treated with intravenous prostaglandin E₁ obtained on echo records using a hand held echo scanner (SonoHeart) and a high frequency 5-7 MHz curved array probe.

Figure 7  .

(A) Maximal intensity projection of aorta. Image was obtained from a three dimensional gadolinium enhanced acquisition in a 5 year old patient with coarctation of the aorta. Note the elongation of the distal transverse aortic arch, the narrowing of the proximal transverse aortic arch, and the severe stenosis just beyond the left subclavian artery. (B) Surface rendering of the aorta in this patient, obtained by additional processing of the three dimensional gadolinium enhanced acquisition. Surface renderings are easily performed from high quality first pass gadolinium enhanced datasets. H, head; F, feet; L, left; R, right; P, posterior.

Figure 8  .

Multiple local maximal intensity projections obtained from a single three dimensional gadolinium enhanced acquisition. The patient was a 1.7 kg premature infant with pulmonary valve atresia and very poor echocardiographic windows who was intubated and dependent on a prostaglandin infusion. LSVC, left superior vena cava; S, superior; R, right; L, left; I, inferior; RPA, right pulmonary artery; TAA, transverse aortic arch; LPA, left pulmonary artery; Asc Ao, ascending aorta; PDA, patent ductus arteriosus; Desc Ao, descending aorta.

Figure 9  .

Magnetic resonance study obtained in a 15 month old patient with polysplenia and partial anomalous pulmonary venous connection. (A) Superior transverse section obtained with multiphasic gradient echo technique and subsequent four dimensional maximal intensity projection. Section shows anomalous connection of right upper pulmonary vein (RUPV) to right atrium. The left upper pulmonary vein (LUPV) connects normally to the left atrium. The interatrial septum (IAS) is intact in this section. (A, anterior). (B) Middle transverse section showing normal connection of left lower pulmonary vein to left atrium. (C) Lower transverse section showing anomalous connection of right lower pulmonary vein to right atrium. (D) Coronal section obtained with gadolinium angiography and SENSE technique also showing anomalous pulmonary venous connection of the right pulmonary veins to right atrium (S, superior; I, inferior).

Figure 10  .

Magnetic resonance study from an 18 year old patient status post Rastelli repair for transposition of the great arteries, ventricular septal defect, and pulmonary stenosis. The patient had developed superior vena caval obstruction. Sections obtained with multiphasic gradient echo technique and subsequent four dimensional maximal intensity projection. (A) Anterior coronal section shows complete obstruction of upper portion of superior vena cava (SVC). (B) Posterior coronal section shows large azygos vein (AZ). (C). Transverse section showing large azygos vein. Note the presence of multiple venous collateral vessels.

Figure 11  .

Magnetic resonance study from 26 year old patient with dextrocardia and complete atrioventricular canal defect who was status post modified Fontan procedure. (A) Transverse black blood image generated with double inversion technique. Note the position of the lateral tunnel (LT). (B) Typical white blood image generated with gradient echo technique. Again, note the position of the lateral tunnel.

Figure 12  .

(A) Local maximal intensity projection from three dimensional navigator acquisition in 14 year old patient with normal coronary arteries (RCA, right coronary artery, LMCA, left main coronary artery). (B) Local maximal intensity projection from three dimensional navigator acquisition in 16 year old patient with anomalous origin of the left main coronary artery from the posterior sinus of Valsalva. Note that the left main coronary artery originates at an acute angle from the posterior sinus. The patient presented for medical attention because of exercise induced chest pain and was noted to have premature ventricular contractions at peak exercise. (C) Local maximal intensity projection from three dimensional navigator acquisition in 13 year old patient with anomalous acute origin of the right coronary artery from the left sinus of Valsalva.

Figure 13  .

Magnetic resonance image obtained from 17 year old patient with an aneurysm (An) of the upper descending aorta subsequent to coarctation repair. The section was acquired with a black blood double inversion spin echo technique. Note that the image is diastolic, as evidenced by the closed aortic valve (AoV) leaflets.

Figure 14  .

Images obtained with balanced fast field echo technique in 24 year old patient with Marfan's syndrome. Note the high contrast between the blood pool and the cardiac and blood vessel walls. Images were taken from short (five second) breath hold multiphasic acquisitions. (A) Short axis at level of aortic root. (B) Long axis section. (C) Short axis at mid ventricular level.

Figure 15  .

Ten year old patient with uncorrected tetralogy of Fallot. A severely stenotic classic Blalock-Taussig shunt (BT) is present. Images were obtained from a three dimensional gadolinium enhanced acquisition with the SENSE technique. (A) Maximal intensity projection from first dynamic volume. Note that the pulmonary arteries are opacified, but that only a small amount of contrast is present in the aorta. The speed of SENSE greatly facilitates acquisition of first pass pulmonary volumes. (B) Maximal intensity projection from second dynamic volume. The aorta and pulmonary veins are well demonstrated on this projection, but systemic venous opacification is minimal except for the superior vena cava. (C) Another maximal intensity projection from the second dynamic volume, demonstrating the descending aorta and the absence of major aortopulmonary collateral vessels.

Figure 16  .

Pulmonary and systemic arterial flow determination by phase contrast magnetic resonance imaging in a 17 year old patient with partial anomalous pulmonary venous connection. (A) Coronal positioning scan for aortic acquisition, showing position of aortic phase contrast section. (B) Magnitude image from aortic phase contrast section. (C) Corresponding phase image from aortic section. (D) Sagittal positioning scan for pulmonary acquisition, showing position of pulmonary phase contrast section. (E) Magnitude image from pulmonary phase contrast section. (F) Corresponding phase image from pulmonary section. (G) Calculated systemic and pulmonary flow rates. Calculated Qp:Qs ratio was 2.17:1.

Figure 17  .

Tagged short axis images at the mid ventricular level in 16 year old patient with normal heart. (A) Diastolic image. (B) Systolic image. Note the distortion of the tagging lines on the systolic frame.

Figure 18  .

Coronal plane phase contrast magnetic resonance study in a patient with an atriopulmonary type of Fontan operation. Magnetic resonance phase velocity mapping showing flow direction (represented by vectors) and flow velocity (represented by the length of each vector). Illustration courtesy of Tal Geva, MD, Boston Children's Hospital, Harvard Medical School.