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(Circulation. 2000;102:e71.)
© 2000 American Heart Association, Inc.

Images in Cardiovascular Medicine

Magnetic Resonance Angiography of a Pulmonary Artery Stenosis Late After Cardiac Surgery

Robert J. M. van Geuns, MD; Matthijs Oudkerk, MD, PhD; Pim J. de Feyter, MD, PhD; Silja E. Spitaels, MD, PhD

From the Department of Cardiology, Thoraxcenter (R.J.M.v.G., P.J.d.F., S.E.S.) and the Department of Radiology, Dr Daniel den Hoedkliniek, University Hospital Rotterdam (M.O.), Rotterdam, The Netherlands.

Correspondence to Robert J.M. van Geuns, MD, Department of Cardiology, Thoraxcenter, Bd 406, University Hospital Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands. E-mail vangeuns{at}card.azr.nl

A19-year-old man with known dextrocardia, situs inversus, and complete surgical correction of a double-outlet right ventricle was seen in the outpatient clinic for follow-up after total correction, including the implantation of a pulmonary homograft. During echocardiography, a dilated right atrium and right ventricle were noted. Increased right ventricular pressure (50 mm Hg; tricuspid regurgitation, 3.5 m/s) could only partially be explained by pulmonary valve stenosis. The pulmonary artery branches could not be visualized echocardiographically. Magnetic resonance angiography was performed using the breath-hold contrast-enhanced 3D gradient echo sequence described by Prince et al.¹ The imaging time was 24 seconds and the resolution was 1.0x2.6x1.3 mm. After the acquisition, the datasets were transferred to a dedicated graphic workstation (Indigo2, Silicon Graphics) for 3D evaluation with a volume-rendering technique^{2 3} using commercially available software (VoxelView, Vital Images). Three-dimensional representation with volume rendering showed the situs inversus very clearly (Figure 1). The pulmonary homograft is located on the right side of the patient, with the ascending aorta on the left and descending aorta to the right of the spine. The branch vessels are reversed, with a left brachiocephalic artery as the first arch branch.

View larger version (115K): [in this window] [in a new window]   Figure 1. Breath-hold contrast-enhanced magnetic resonance angiography of a patient with situs inversus. Ao indicates aorta; PA, pulmonary artery; RV, right ventricle; RA, right atrium; R, right side of patient; and L, left side of patient. Arrow indicates left brachiocephalic artery.

To visualize the pulmonary artery branches, the heart and aorta were subtracted from the source images (Figure 2). Both the pulmonary arteries and veins are filled with contrast. The right pulmonary artery showed an important stenosis at the anastomosis from the pulmonary homograft. Figure 3 is a detailed view of the origin of the right pulmonary artery.

View larger version (149K): [in this window] [in a new window]   Figure 2. Visualization of the pulmonary artery (PA) after removal of the heart and aorta from the dataset. The pulmonary veins are also visualized (arrowheads). The right pulmonary artery shows an important stenosis at the origin (straight arrow). R indicates right side of patient; L, left. The 3D rotation of this image can be found at www.circulationaha.org

View larger version (135K): [in this window] [in a new window]   Figure 3. Detailed view of the common pulmonary artery (PA) and proximal right pulmonary artery showing a stenosis at the origin (straight arrow).

The diagnosis was confirmed during reoperation, which consisted of implanting a new pulmonary homograft and reconstructing the right pulmonary artery.

Footnotes

A movie version of Figure 2 (showing 3D rotation) can be found at www.circulationaha.org

The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.

Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1–267, Houston, TX 77030.

References

1. Prince MR, Narasimham DL, Stanley JC, et al. Breath-hold gadolinium-enhanced MR angiography of the abdominal aorta and its major branches. Radiology. 1995;197:785–792.[Abstract/Free Full Text]
   
2. Fishman EK, Magid D, Ney DR, et al. Three-dimensional imaging. Radiology. 1991;181:321–337.[Free Full Text]
   
3. Johnson PT, Heath DG, Kuszyk BS, et al. CT angiography with volume rendering: advantages and applications in splanchnic vascular imaging. Radiology. 1996;200:564–568.[Abstract/Free Full Text]
   

This Article Full Text (PDF) Data Supplement Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by van Geuns, R. J. M. Articles by Spitaels, S. E. Search for Related Content PubMed PubMed Citation Articles by van Geuns, R. J. M. Articles by Spitaels, S. E. Related Collections Pulmonary circulation and disease CT and MRI Pediatric and congenital heart disease, including cardiovascular surgery