Dynamic Contrast-Enhanced MRI Before and After Transcatheter Occlusion of Patent Foramen Ovale
Oliver K. Mohrs1,2,
Steffen E. Petersen3,
Damir Erkapic4,
Anja Victor5,
Thomas Schlosser6,
Bernd Nowak7,
Guenter Kauffmann8,
Thomas Voigtlaender7 and
Hans-Ulrich Kauczor2
1 Darmstadt Radiology, Department of Cardiovascular Imaging at Alice-Hospital,
Dieburger Strasse 29-31, 64287 Darmstadt, Germany.
2 German Cancer Research Center, 69120 Heidelberg, Germany.
3 Centre for Clinical Magnetic Resonance Imaging, University of Oxford, Oxford
OX3 9DU, United Kingdom.
4 Kerckhoff-Klinik, Bad Nauheim D-61231, Germany.
5 Institute of Medical Biostatistics, Epidemiology and Informatics, Mainz
D-55101, Germany.
6 Department of Radiology, University of Essen, Essen D-45122, Germany.
7 Cardiovascular Center Bethanien, Frankfurt/Main D-60389, Germany.
8 Department of Radiology, University of Heidelberg, Heidelberg D-69120,
Germany.
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Fig. 1A —42-year-old man with right-to-left shunt before and absence
of residual shunt after occlusion of patent foramen ovale (PFO). Temporal
sequence of contrast-enhanced dynamic perfusion images during Valsalva
maneuver before transcatheter occlusion of PFO. Images show baseline signal
intensity without enhancement, (RA = right atrium, RV = right ventricle, LA =
left atrium, LV = left ventricle, PV = pulmonary vein, PA = pulmonary artery)
(A), enhancement of right atrium, slight enhancement of pulmonary
artery, and enhancement of entire left atrium due to right-to-left-shunt
(arrow) before enhancement of pulmonary vein (B), decrease in
signal intensity in left atrium representing dip back to baseline after first
initial peak (C), and enhancement of pulmonary vein and second signal
peak in left atrium (D).
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Fig. 1B —42-year-old man with right-to-left shunt before and absence
of residual shunt after occlusion of patent foramen ovale (PFO). Temporal
sequence of contrast-enhanced dynamic perfusion images during Valsalva
maneuver before transcatheter occlusion of PFO. Images show baseline signal
intensity without enhancement, (RA = right atrium, RV = right ventricle, LA =
left atrium, LV = left ventricle, PV = pulmonary vein, PA = pulmonary artery)
(A), enhancement of right atrium, slight enhancement of pulmonary
artery, and enhancement of entire left atrium due to right-to-left-shunt
(arrow) before enhancement of pulmonary vein (B), decrease in
signal intensity in left atrium representing dip back to baseline after first
initial peak (C), and enhancement of pulmonary vein and second signal
peak in left atrium (D).
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Fig. 1C —42-year-old man with right-to-left shunt before and absence
of residual shunt after occlusion of patent foramen ovale (PFO). Temporal
sequence of contrast-enhanced dynamic perfusion images during Valsalva
maneuver before transcatheter occlusion of PFO. Images show baseline signal
intensity without enhancement, (RA = right atrium, RV = right ventricle, LA =
left atrium, LV = left ventricle, PV = pulmonary vein, PA = pulmonary artery)
(A), enhancement of right atrium, slight enhancement of pulmonary
artery, and enhancement of entire left atrium due to right-to-left-shunt
(arrow) before enhancement of pulmonary vein (B), decrease in
signal intensity in left atrium representing dip back to baseline after first
initial peak (C), and enhancement of pulmonary vein and second signal
peak in left atrium (D).
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Fig. 1D —42-year-old man with right-to-left shunt before and absence
of residual shunt after occlusion of patent foramen ovale (PFO). Temporal
sequence of contrast-enhanced dynamic perfusion images during Valsalva
maneuver before transcatheter occlusion of PFO. Images show baseline signal
intensity without enhancement, (RA = right atrium, RV = right ventricle, LA =
left atrium, LV = left ventricle, PV = pulmonary vein, PA = pulmonary artery)
(A), enhancement of right atrium, slight enhancement of pulmonary
artery, and enhancement of entire left atrium due to right-to-left-shunt
(arrow) before enhancement of pulmonary vein (B), decrease in
signal intensity in left atrium representing dip back to baseline after first
initial peak (C), and enhancement of pulmonary vein and second signal
peak in left atrium (D).
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Fig. 1E —42-year-old man with right-to-left shunt before and absence
of residual shunt after occlusion of patent foramen ovale (PFO). MR images
show results after transcatheter occlusion with Amplatzer device (AGA
Medical). Artificial loss of signal intensity caused by occluder device
(circle, E) is evident. In contrast to examination before
occlusion, enhancement of left atrium before enhancement of pulmonary vein due
to right-to-left shunt can be excluded.
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Fig. 1F —42-year-old man with right-to-left shunt before and absence
of residual shunt after occlusion of patent foramen ovale (PFO). MR images
show results after transcatheter occlusion with Amplatzer device (AGA
Medical). Artificial loss of signal intensity caused by occluder device
(circle, E) is evident. In contrast to examination before
occlusion, enhancement of left atrium before enhancement of pulmonary vein due
to right-to-left shunt can be excluded.
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Fig. 1G —42-year-old man with right-to-left shunt before and absence
of residual shunt after occlusion of patent foramen ovale (PFO). MR images
show results after transcatheter occlusion with Amplatzer device (AGA
Medical). Artificial loss of signal intensity caused by occluder device
(circle, E) is evident. In contrast to examination before
occlusion, enhancement of left atrium before enhancement of pulmonary vein due
to right-to-left shunt can be excluded.
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Fig. 1H —42-year-old man with right-to-left shunt before and absence
of residual shunt after occlusion of patent foramen ovale (PFO). MR images
show results after transcatheter occlusion with Amplatzer device (AGA
Medical). Artificial loss of signal intensity caused by occluder device
(circle, E) is evident. In contrast to examination before
occlusion, enhancement of left atrium before enhancement of pulmonary vein due
to right-to-left shunt can be excluded.
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Fig. 2A —42-year-old man with right-to-left shunt. Same patient as in
Figure 1A,
1B,
1C,
1D,
1E,
1F,
1G,
1H. With patent foramen ovale
(PFO) (A) and after transcatheter occlusion of PFO (B). Signal
intensity-time curve (A) shows early initial signal peak
(arrow) (167% of baseline signal) in left atrium (squares)
followed by second higher peak before peak in pulmonary vein
(circles) before PFO occlusion. Signal intensity-time curve after PFO
occlusion (B) shows only slight signal variability (up to 118% of
baseline signal) compared with baseline signal intensity.
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Fig. 2B —42-year-old man with right-to-left shunt. Same patient as in
Figure 1A,
1B,
1C,
1D,
1E,
1F,
1G,
1H. With patent foramen ovale
(PFO) (A) and after transcatheter occlusion of PFO (B). Signal
intensity-time curve (A) shows early initial signal peak
(arrow) (167% of baseline signal) in left atrium (squares)
followed by second higher peak before peak in pulmonary vein
(circles) before PFO occlusion. Signal intensity-time curve after PFO
occlusion (B) shows only slight signal variability (up to 118% of
baseline signal) compared with baseline signal intensity.
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Fig. 3A —62-year-old man with medium-grade residual shunt on
transesophageal echocardiography after occlusion of patent foramen ovale with
CardiaStar device (Cardia). MR image shows baseline signal without
enhancement.
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Fig. 3B —62-year-old man with medium-grade residual shunt on
transesophageal echocardiography after occlusion of patent foramen ovale with
CardiaStar device (Cardia). MR image shows enhancement of right atrium,
pulmonary artery, and entire left atrium due to residual shunt before
enhancement of pulmonary vein.
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Fig. 3C —62-year-old man with medium-grade residual shunt on
transesophageal echocardiography after occlusion of patent foramen ovale with
CardiaStar device (Cardia). MR image shows decrease in signal intensity in
left atrium representing dip back to baseline after first initial peak.
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Fig. 3D —62-year-old man with medium-grade residual shunt on
transesophageal echocardiography after occlusion of patent foramen ovale with
CardiaStar device (Cardia). MR image shows enhancement of pulmonary vein and
second signal-intensity peak in left atrium.
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Fig. 4 —Median signal intensity normalized to baseline signal
intensity (second image after contrast injection and start of image
acquisition) for patients with and without patent foramen ovale (PFO) and with
and without residual shunt after PFO device implantation. Dashed line at 129%
signal intensity of baseline signal represents proposed cutoff value for
diagnosis of shunt for first peak in left atrium (LA). PV = pulmonary
vein.
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Fig. 5 —Receiver operating characteristic curves show relations of
sensitivity to 1 - specificity for different values of relative peak
(solid line) in left atrium and relative level (dashed line)
after first peak. Ideal of 100% sensitivity and 100% specificity would be
reached in upper left corner.
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