Myocardial Perfusion, Scarring, and Function in Anomalous Left Coronary Artery From the Pulmonary Artery Syndrome: A Long-Term Analysis Using Magnetic.

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Presentation transcript:

Myocardial Perfusion, Scarring, and Function in Anomalous Left Coronary Artery From the Pulmonary Artery Syndrome: A Long-Term Analysis Using Magnetic Resonance Imaging Boris Schmitt, MD, Sina Bauer, MD, Shelby Kutty, MD, Sarah Nordmeyer, MD, Boris Nasseri, MD, Felix Berger, MD, PhD, Vladimir Alexi- Meskishvili, MD, PhD The Annals of Thoracic Surgery Volume 98, Issue 4, Pages 1425-1436 (October 2014) DOI: 10.1016/j.athoracsur.2014.05.031 Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Description and order of magnetic resonance imaging sequences applied to examine cardiac morphology, including coronary ostia, mitral flow, myocardial perfusion, wall motion, and late gadolinium enhancement. (2CH = 2-chamber view cine sequence; 2D/QF/MK = two-dimensional quantitative flow analysis at the mitral valve; 3CH = 3-chamber view cine sequence; axi6mm = axial/transverse slice orientation with 6 mm slice thickness; bTFE = balanced turbo field echo; CineTransHP = Cine sequence with high temporal resolution of 50 images per heart beat; CoroScout = planning sequence for coronary artery scanning; Perf = perfusion; p4CH = pseudo 4-chamber view cine sequence; RAO = right anterior oblique; REF = reference scan for cardiac coil; sSA = short axis; sSAwh = short axis covering whole heart without gap; VIAB = viability.) The Annals of Thoracic Surgery 2014 98, 1425-1436DOI: (10.1016/j.athoracsur.2014.05.031) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Magnetic resonance imaging measurement across the mitral valve plane shows a competent valve closure (minimal regurgitation fraction of 3.2%) and normal E- and A-waves. (A) Graphical and (B) numerical display of the flow results measured within the region of interest (ROI). The ROI is marked in (B) anatomical view and (C) phase contrast view. The Annals of Thoracic Surgery 2014 98, 1425-1436DOI: (10.1016/j.athoracsur.2014.05.031) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Myocardial perfusion displayed in a 3-level 6-segment model shows low perfusion of the left ventricular (LV) apex and anterior wall as typically seen in anomalous left coronary artery from the pulmonary artery. The Annals of Thoracic Surgery 2014 98, 1425-1436DOI: (10.1016/j.athoracsur.2014.05.031) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 (A) The characteristic high-level origin of the reinserted left coronary artery is displayed in a 2-dimensional grey-scale image. (B) A 3-dimensional reconstruction of a magnetic resonance imaging sequence of the entire heart shows the wide-open funnel-shaped anastomosis. The Annals of Thoracic Surgery 2014 98, 1425-1436DOI: (10.1016/j.athoracsur.2014.05.031) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Box-and-whisker plots show (A) left ventricular ejection fraction, (B) left ventricular fractional shortening, (C) left ventricular end diastolic diameter (LVEDD)/body surface area (BSA), and (D) mitral insufficiency as measured by echocardiography (echo; white) and magnetic resonance imaging (MRI; black). The horizontal line in the middle of each box indicates the median; the top and bottom borders of the box mark the 75th and 25th percentiles, respectively, and the whiskers mark the 90th and 10th percentiles. *p < 0.05. (E) Each patient's grade of mitral regurgitation (MR) is connected by colored lines throughout the four time points of follow-up. Broken lines indicate patients with mitral valve repair. Type of repair is specified below. The Annals of Thoracic Surgery 2014 98, 1425-1436DOI: (10.1016/j.athoracsur.2014.05.031) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 (A) Box-and-whisker plot shows collateral flow (good, white; poor, shaded) vs left ventricular end-diastolic diameter (LVEDD)/body surface area (BSA). The horizontal line in the middle of each box indicates the median; the top and bottom borders of the box mark the 75th and 25th percentiles, respectively, and the whiskers mark the 90th and 10th percentiles. *p < 0.05. Flow chart shows collateral flow and myocardial perfusion by cardiac magnetic resonance imaging (MRI). (B) Patients tested for myocardial perfusion under rest conditions, results sorted by collateralization before repair. (C) Same patients as in (B) tested for perfusion during dobutamin infusion and sorted by initial collateral flow. The number of patients with perfusion deficit increases during dobutamin testing in both groups, but more pronounced in patients with initial poor collateral flow than with good collateralization. At rest 40% (4 of 10) of patients with former poor collateralization show perfusion deficit, at stress 67% (6 out of 9). In the group with good collateral flow before repair 11% (1 out of 9) show perfusion deficit at rest and 25% (2 out of 8) at stress. The Annals of Thoracic Surgery 2014 98, 1425-1436DOI: (10.1016/j.athoracsur.2014.05.031) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 7 Flow chart shows detection of new (A) myocardial wall motion abnormalities (WMA) and (B) perfusion deficits (PD) by cardiac magnetic resonance imaging (MRI) dobutamine stress testing. The Annals of Thoracic Surgery 2014 98, 1425-1436DOI: (10.1016/j.athoracsur.2014.05.031) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 8 Comparison of (A) wall motion abnormalities (WMA) vs perfusion deficit at rest, (B) WMA vs perfusion deficit at stress, (C) WMA at rest vs late gadolinium enhancement, and (D) and late gadolinium enhancement vs perfusion deficit at stress Data are expressed as median ± range. *p < 0.05. The Annals of Thoracic Surgery 2014 98, 1425-1436DOI: (10.1016/j.athoracsur.2014.05.031) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 9 Analysis of exercise testing, measured as (A) maximum volume of oxygen consumption (Vo2 max) vs myocardial late enhancement, (B) Vo2 max vs wall motion abnormalities, and (C) Vo2 max vs ejection fraction on magnetic resonance imaging. In panel A, the horizontal line in the middle of each box indicates the median; the top and bottom borders of the box mark the 75th and 25th percentiles, respectively, and the whiskers mark the 90th and 10th percentiles, In panel C, the vertical split point shows a patient who reached suboptimal results in exercise testing despite a good ejection fraction, and the horizontal split point shows a patient who had a low ejection fraction, but had normal exercise performance. The Annals of Thoracic Surgery 2014 98, 1425-1436DOI: (10.1016/j.athoracsur.2014.05.031) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions