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acr-spr mr imaging of congenital and pediatric cardiovascular mr disorders

Pediatric Cardiovascular MR Techniques. Cynthia K. Rigsby, MDDepartment of MedicalImagingChildren's Memorial Hospital Chicago, IL. Disclosure. The use of gadolinium for MRA and for power injection is considered

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acr-spr mr imaging of congenital and pediatric cardiovascular mr disorders

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    1. ACR-SPR MR Imaging of Congenital and Pediatric Cardiovascular MR Disorders Individual workstations for all attendees Leading vendor cardiovascular MR post-processing software at every workstation Emphasis on computer-based self-paced learning with significant one-to-one faculty-to-attendee interaction

    4. Pediatric Cardiovascular MR Techniques Structure Function Flow Tissue Composition Case examples

    6. White BloodSteady State Free Precession Balanced FFP, FIESTA, True FISP High contrast to noise ratio Low TE values Lessen turbulent flow artifacts

    7. White BloodGradient Echo Accentuate turbulent flow jets Higher TE values than SSFP

    8. White BloodGradient Echo Severe banding/off-resonance artifacts on SSFP imaging

    9. White BloodGradient Echo Infants/small children if TR for SSFP imaging >> 4 ms

    11. Adult lost to follow up and no available records. Short of breath. Echo (poor windows) showed CC-TGV and LV (subpulmonary) to PA conduit. Evaluate anatomy and function.

    12. 3D SSFP

    15. Black Blood Characterize myocardial structure and composition Double inversion recovery fast spin echo/HASTE T1 SE May be performed with fat suppression and/or post contrast

    16. Black Blood 7 yo male chest pain, vomiting, heart rate of 250 bpm Echo large mass

    17. Black Blood MRI and biopsy c/w fibroma

    22. ECG-gated MRATeen with probable coarctation

    24. Time-Resolved MRA

    25. Time-Resolved MRA 10 yo with dyspnea on exertion

    26. Function SSFP imaging Myocardial tagging

    27. Function Systolic function How well the heart contracts during systole to force blood out of the ventricles RV and LV systolic function assessed with ejection fractions Endocardial border tracings on systolic and diastolic images 16 yo female TOF s/p repair

    29. Probability of major adverse clinical outcomes -death, sustained VT, functional deterioration-late (median 21 years) after TOF repairmedian follow-up 4.2 years

    30. Function Diastolic function How well the heart relaxes Diastolic dysfunction Limitation in ventricular relaxation causing impairment of ventricular filling during diastole Can precede systolic dysfunction More difficult than systolic function to directly measure

    31. Function

    32. Function Myocardial tagging can be used to assess systolic and diastolic function Parallel RF pulses saturate tissue and lead to tags Qualitative analysis Subjective and not reproducible over time

    35. Phase Contrast Imaging Pulmonary valve regurgitation Image perpendicular to vessel of interest Adequate temporal and spatial resolution Accurate velocity and blood flow measurements 16 yo TOF s/p repair

    36. Phase Contrast Imaging Flow direction White Black Gray Velocity Flow volume Velocity Vessel area

    37. Phase Contrast Imaging Regurgitant fraction Backward flow/forward flow 34/56 ml/beat 60% regurgitant fraction

    38. Phase Contrast Imaging

    39. Tissue Composition T2* Myocardial delayed enhancement Perfusion

    40. T2* Iron overload states ߖthalassemia/Sickle cell disease/Hemochromatosis Iron accumulation in organs including heart and liver Chelation therapy to remove excess iron May or may not be completely successful Cardiac complications due to iron overload are leading cause of death in thalassemia Cardiac failure directly correlates with cardiac iron burden

    41. T2* Principles T2* is an MRI signal decay rate Greater iron in magnetic field increases field inhomogeneity and shortens T2* T2* values correlate with heart and liver iron load T2* imaging replacing liver biopsy and used to direct chelation therapy

    42. T2* Gradient echo pulse sequence with multiple TE values Mono-exponential decay curve fit to the MRI data Slope = 1000/T2* Higher iron content will have steeper curve and lower T2*

    43. T2*

    44. T2*

    45. Tissue CompositionMyocardial Delayed Enhancement Gadolinium rapidly equilibrates between extracellular space and interstitium Washes in and washes out of normal myocardium Slower wash in and wash out from damaged myocardium Delayed enhancement Images performed 15 minutes following contrast Scar or myocardial replacement fibrosis

    46. Myocardial Delayed Enhancement

    47. Myocardial Delayed Enhancement Hypertrophic cardiomyopathy Patchy MDE in area of hypertrophy Indicative of replacement fibrosis MDE associated with markers for risk of sudden cardiac death and progressive disease

    48. Myocardial Delayed Enhancement Thrombus imaging Failed classic Fontan patients prior to Fontan conversion surgery Retrospective review No false negative MRI studies for thrombus compared with surgical findings

    49. Myocardial Delayed Enhancement 3 year old with chest pain, abnormal ECG, and elevated cardiac enzymes Delayed enhancement Myocarditis May be nodular, subepicardial Does not respect vascular territories Cath negative; biopsy c/w myocarditis

    50. Perfusion ImagingFirst Pass Contrast Enhancement

    51. Myocardial Delayed Enhancement Idiopathic hypereosinophilic syndrome Eosinophil mediated organ damage Thrombus Inflammation/fibrosis Restrictive cardiomyopathy (late)

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