Segmental approach to imaging of congenital heart disease.

The segmental approach, which is widely used in the imaging work-up of congenital heart disease, consists of a three-step evaluation of the cardiac anatomy. In step 1, the visceroatrial situs is determined. Visceroatrial situs refers to the position of the atria in relation to the nearby anatomy (including the stomach, liver, spleen, and bronchi). Three different anatomic configurations may be observed: situs solitus (normal), situs inversus (inverted), or situs ambiguus (ambiguous). In step 2, the left- or rightward orientation of the ventricular loop is evaluated, and the positions of the ventricles are identified on the basis of their internal morphologic features. In step 3, the position of the great vessels is determined first, and any abnormalities are noted. Abnormalities in the origin of the great vessels, or conotruncal anomalies, are predominantly of three types: D-transposition (dextrotransposition), L-transposition (levotransposition), and D-malposition with double outlet right ventricle. Next, the relationships between the atria and ventricles and the ventricles and great vessels are determined at two levels: atrioventricular (concordant, discordant, ambiguous, double inlet, absence of right or left connection) and ventriculoarterial (concordant, discordant, double outlet). Last, a search is performed for any associated abnormalities of the cardiac chambers, septa, outflow tract, and great vessels. By executing these steps sequentially during image review, the radiologist can achieve a more accurate interpretation. Multiplanar reconstructions of cross-sectional image data obtained with computed tomography or magnetic resonance imaging are particularly useful for evaluating congenital heart disease.

Follow-up chest X-ray in patients with Kawasaki disease: the significance and clinical application of coronary artery macro-calcification.

Kawasaki disease (KD) related coronary artery (CA) aneurysms may lead to significant and potentially insidious progressive stenosis. It is also well recognized that CA scarring leads to heavy calcification in KD. We intended to correlate the angiographic anomalies associated with coronary calcifications in KD and to evaluate the chronology and the detection rate of KD-related CA calcification on plain chest X-ray. Between 1992 and 2006, 65 CA angiograms were performed in 50 KD patients. Chest fluoroscopies and angiograms were retrospectively reviewed. When angiograms were abnormal, chest X-rays were reviewed by two radiologists blinded to the results of angiograms. CA lesions were identified in 18/50 (36%) patients, including isolated CA aneurysms in 10. All 8 patients who had CA aneurysms associated with stenosis and/or occlusion had CA calcification identifiable on chest X-ray. All significant stenotic lesions were concomitant with calcification. Plain chest X-ray, a simple inexpensive low dose mean, easily identifies KD patients at risk for serious CA stenosis when specific search for CA calcification is pursued. When detected, a closer tracking of coronary artery patency is warranted via other imaging techniques, usually expensive, invasive, requiring sedation in children or exposing to high radiation.

The role of cardiac magnetic resonance in the diagnosis of anomalous pulmonary venous return with subsequent Amplatzer device treatment.

We report the case of a young girl with a mixed total anomalous pulmonary venous return (cardiac and supracardiac) treated sequentially by partial neonatal surgery, and then catheterization at age 19 with installation of an Amplatzer device as a treatment of the remaining anomaly. We describe the usefulness of magnetic resonance imaging in both the diagnosis and follow-up of this anomaly.

The effect of Picture Archiving and Communications Systems on the accuracy of diagnostic interpretation of pediatric emergency physicians.

OBJECTIVES: To compare the accuracy of diagnostic interpretation of radiographs by pediatric emergency physicians (EPs) before and after the introduction of a Picture Archiving and Communications System (PACS). METHODS: The pre-PACS study period included results from September 2001, when patients were evaluated by using only conventional radiographs. The post-PACS study period consisted of results from September 2002, when patients were evaluated by using only digital radiographic studies. During these periods, consecutive medical records of all patients who underwent radiological studies when attending the pediatric emergency department (ED) were reviewed. The radiographic interpretation by the pediatric EP, documented at the time of the ED visit, was compared with that made by the pediatric radiologist. RESULTS: Data were available from 1,644/1,651 sets of conventional radiographs ordered for the pre-PACS study period and from 1,430/1,431 sets of digital radiographic studies for the post-PACS study period. The prevalence of positive radiological studies as per the radiologists was 32.2% (pre-PACS study period) vs. 28.7% (post-PACS study period). Diagnostic performance of the pediatric EPs for the two time periods was as follows: overall accuracy, 98.1% (95% confidence interval [CI] = 94.5% to 100%) vs. 98.5% (95% CI = 87.5% to 100%); sensitivity, 96.4% (95% CI = 94.5% to 97.8%) vs. 98.1% (95% CI = 96.2% to 99.2%); specificity, 98.9% (95% CI = 98.1% to 99.4%) vs. 98.6% (95% CI = 97.7% to 99.3%); negative predictive value, 98.3% (95% CI = 97.4% to 99.0%) vs. 99.2% (95% CI = 98.5% to 99.7%); and positive predictive value, 97.7% (95% CI = 96.0% to 98.8%) vs. 96.6% (95% CI = 94.4% to 98.2%). The proportion of false negatives (FN) was 1.2% (19/1,644) vs. 0.6% (8/1,430). Only one FN patient for each time period required immediate follow-up for a missed diagnosis. CONCLUSIONS: Radiograph interpretations by pediatric EPs with digital studies remain as accurate in comparison with assessments performed by using conventional radiographs.

[Magnetic resonance imaging in congenital anomalies of the thoracic veins]. / L'apport de la résonance magnétique dans les anomalies congénitales des veines thoraciques.

Congenital anomalies of the thoracic veins, although uncommon, can be of the utmost clinical and surgical significance. These venous anomalies may be subdivided into systemic and pulmonary. Most systemic venous abnormalities are incidental findings, whereas pulmonary vein malformations coexist with coronary heart disease, especially atrial septal defect. Although cardiac ultrasonography remains the initial noninvasive imaging modality, magnetic resonance imaging with ultrafast sequences is of great diagnostic value because multiplanar 3-dimensional reconstructions may be made.

Evaluation of a large atrial septal occluder with cardiac MR imaging.

Magnetic resonance (MR) imaging was used to evaluate the position of a large atrial septal occluder (ASO) with regard to adjacent cardiac valves and veins and to assess any negative effects of the ASO on these vital structures. A total of 26 pediatric patients (mean age, 4.5 years; mean interval after implantation, 18.8 months) were evaluated with cardiac MR imaging. The position of the ASO was best depicted with two-dimensional cine fast low-angle shot imaging. The authors observed impingement of the ASO on the right superior pulmonary vein in 14 patients, on the right inferior pulmonary vein in three patients, on the right superior vena cava in 13 patients, and on the right inferior vena cava in nine patients. In two patients, protrusion of the ASO into the right inferior vena cava was associated with coronary sinus prominence. The ASO was in contact with the mitral valve in 10 patients. Deformation of the aortic valve and root was evident at the onset of the R wave in 19 patients and persisted throughout the cardiac cycle in five of these patients. Cardiac MR imaging reliably depicted the position of the ASO with regard to vital structures. Despite the protrusion of the ASO, no significant effects on venous structures or cardiac valves were observed.