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Postoperative Imaging in Cyanotic Congenital Heart Diseases: Part 1, Normal Findings

¹ Department of Radiology, Complejo Hospitalario Universitario Juan Canalejo, Xubias de Arriba 84, 15006 La Coruña, Spain.
² Department of Pediatric Cardiology, Complejo Hospitalario Universitario Juan Canalejo, La Coruña, Spain.

View larger version (21K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —Blalock-Taussig shunt. Sketch of Blalock-Taussig shunt. Drawing shows classic Blalock-Taussig procedure in which end-to-side anastomosis (gray) is performed between subclavian artery and ipsilateral pulmonary artery, usually on side opposite descending aorta. Although this procedure provides shunt flow appropriate for patient who is size of infant, it requires careful, lengthy dissection and distorts peripheral pulmonary artery.

View larger version (22K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —Blalock-Taussig shunt. Sketch shows modified Blalock-Taussig shunt, in which prosthetic graft material (gray) is inserted between subclavian artery and ipsilateral pulmonary artery. With this modified shunt, which can be performed on either side, subclavian blood supply to arm is preserved.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —Blalock-Taussig shunt. Oblique coronal thin-slab reformatted maximum-intensity-projection image obtained with gadolinium-enhanced 3D MR angiography shows patent modified Blalock-Taussig shunt (arrows) from right subclavian artery to pulmonary artery. Procedure was performed for palliative correction of tetralogy of Fallot in 6-year-old boy.

View larger version (14K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —Aortopulmonary shunt. Sketch of Potts shunt. Drawing shows side-to-side anastomosis (gray) between descending aorta and pulmonary artery.

View larger version (15K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —Aortopulmonary shunt. Sketch of Waterston-Cooley shunt. Drawing shows side-to-side anastomosis (gray) of ascending aorta and pulmonary artery.

View larger version (20K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —Aortopulmonary shunt. Sketch shows central shunt, in which prosthetic graft material (gray) is inserted between ascending aorta and main pulmonary artery. Amount of shunt flow is controlled by size of graft (usually 4–5 mm in diameter). This procedure prevents distortion of pulmonary arteries and allows symmetric blood flow and growth.

View larger version (23K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2D —Aortopulmonary shunt. Sketch of Sano shunt shows from right ventricle to pulmonary bifurcation using prosthetic graft conduit (gray). Important advantage of Sano shunt is that flow occurs only during systole. There is no competition between pulmonary and coronary blood flow during diastole, as is case with Blalock shunt.

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2E —Aortopulmonary shunt. Oblique coronal maximum-intensity-projection image shows Sano shunt from right ventricle (arrow) to pulmonary artery (arrowhead) performed for palliative correction of pulmonary atresia in 4-year-old boy.

View larger version (24K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —Modified Glenn shunt. Sketch of bidirectional Glenn shunt. Diagram depicts postoperative anatomy of bidirectional Glenn shunt (gray) in which superior vena cava (SVC) is disconnected from right atrium and anastomosed to undivided right pulmonary artery, providing flow for both lung fields. As with classic Glenn shunt, bidirectional cavopulmonary shunt is less likely to engender pulmonary vascular obstructive disease than systemic artery–to–pulmonary artery shunts and involves only minimal distortion of pulmonary artery architecture.

View larger version (154K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —Modified Glenn shunt. Postoperative anterior 3D shaded surface display (B) and maximum-intensity-projection (C) images show bidirectional Glenn shunt extending from SVC (arrows) to right pulmonary artery (stars) performed for tricuspid atresia and proximal right pulmonary artery stenosis in 20-year-old man. Bright blue and white show SVC and right pulmonary artery, respectively, in C.

View larger version (66K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C —Modified Glenn shunt. Postoperative anterior 3D shaded surface display (B) and maximum-intensity-projection (C) images show bidirectional Glenn shunt extending from SVC (arrows) to right pulmonary artery (stars) performed for tricuspid atresia and proximal right pulmonary artery stenosis in 20-year-old man. Bright blue and white show SVC and right pulmonary artery, respectively, in C.

View larger version (23K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —Fontan procedures. Sketch of original Fontan procedure. Diagram shows conduit between right atrium and pulmonary artery (gray), as in original Fontan procedure.

View larger version (65K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —Fontan procedures. Contrast-enhanced 3D reformatted volume-rendered MR angiography image shows hypoplastic right ventricle (star), large right atrium (arrows), and patent conduit (arrowhead) between right atrial appendage and right pulmonary artery, as in original Fontan procedure, in 12-year-old boy. Yellow shows conduit, blue shows right atrium and right ventricle, and red shows left atrium and left ventricle.

View larger version (23K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C —Fontan procedures. Sketch of Björk modification, which consists of inserting conduit (gray) (often valved) between right atrium and right ventricle.

View larger version (43K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4D —Fontan procedures. Sketch of lateral tunnel procedure. Diagram shows postoperative anatomy of intraatrial tunnel (lateral tunnel procedure). Baffle in right atrium directs inferior vena cava (IVC) flow to lower portion of divided superior vena cava (SVC), which is connected to pulmonary artery. Upper part of SVC is connected to superior aspect of pulmonary artery as in bidirectional Glenn shunts. Right and left pulmonary arteries are interconnected, while pulmonary trunk is disconnected from heart. Most of right atrium is excluded from systemic venous circuit. Gray area shows right atrial baffle connected to right pulmonary artery and IVC, pulmonary trunk disconnected from heart, and SVC to right pulmonary artery anastomosis.

View larger version (33K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4E —Fontan procedures. Sketch shows extracardiac Fontan procedure, in which IVC blood is directed to pulmonary artery via extracardiac conduit. SVC is anastomosed to pulmonary artery, as in modified Glenn shunt, and pulmonary trunk is disconnected from heart. Gray area shows extracardiac conduit connected to right pulmonary artery and IVC, pulmonary trunk disconnected from heart, and SVC to right pulmonary artery anastomosis.

View larger version (46K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4F —Fontan procedures. Reconstructed shaded surface display gadolinium-enhanced 3D MR angiography (F) and coronal cine MR (G) images in 22-year-old woman reveal patency of extracardiac conduit (stars; yellow in F) between IVC and right pulmonary artery (stars) as well as anastomosis of SVC and proximal right pulmonary artery stenosis (arrows, F), as in modified extracardiac Fontan procedure.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4G —Fontan procedures. Reconstructed shaded surface display gadolinium-enhanced 3D MR angiography (F) and coronal cine MR (G) images in 22-year-old woman reveal patency of extracardiac conduit (stars; yellow in F) between IVC and right pulmonary artery (stars) as well as anastomosis of SVC and proximal right pulmonary artery stenosis (arrows, F), as in modified extracardiac Fontan procedure.

View larger version (43K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4H —Fontan procedures. Sketch shows fenestrated Fontan, in which surgical creation of atrial septal defect in atrial patch or baffle (gray) provides escape valve, allowing right-to-left shunting to reduce pressure in systemic venous circuit, with attendant systemic hypoxemia. This fenestration either closes spontaneously or is occluded by device in due course.

View larger version (30K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —Rastelli procedure. Drawing depicts Rastelli procedure postoperative anatomy. In this procedure, prosthetic tunnel (gray) is constructed from left ventricle to aorta through ventricular septal defect. Continuity between right ventricle and main pulmonary artery is restored with extracardiac conduit.

View larger version (52K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —Rastelli procedure. Contrast-enhanced 3D shaded surface display MR angiography oblique coronal image shows conduit (yellow) between right ventricle and main pulmonary artery of Rastelli operation performed for dextrotransposition of great arteries in 28-year-old man with ventricular septal defect and left ventricular outflow tract obstruction.

View larger version (24K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —Pulmonary artery banding. Sketch of pulmonary artery banding. Diagram shows surgical ligature around midportion of main pulmonary artery (gray) causing artificial pulmonary stenosis to reduce systolic pulmonary artery pressure. Repeated progressive occlusion and reopening are possible with new surgically implantable devices that actually behave like adjustable pulmonary artery bands.

View larger version (54K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —Pulmonary artery banding. Reformatted shaded surface display contrast-enhanced 3D MR angiography image depicts correct placement of pulmonary artery band in midportion of main pulmonary artery (arrowhead); procedure was performed for palliative correction of double-outlet right ventricle with large ventricular septal defect in 15-year-old girl. Blue shows right ventricle; yellow shows pulmonary artery banding; and red shows left ventricle, pulmonary veins, and aorta.

View larger version (25K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —Complete surgical correction for tetralogy of Fallot. Sketch of corrective surgery for tetralogy of Fallot. Diagram shows closing of ventricular septal defect and widening of right ventricular outflow tract with patching of infundibular tract (gray).

View larger version (116K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —Complete surgical correction for tetralogy of Fallot. Bulge (arrowhead) visible on this axial cine MR image obtained during diastole is ventricular septal defect closed. Defect was closed during corrective surgery for tetralogy of Fallot in 20-year-old man. No residual left-to-right shunt was found in phase velocity mapping images (not shown).

View larger version (121K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7C —Complete surgical correction for tetralogy of Fallot. Bulge (arrow) of right ventricular outflow tract and of main pulmonary artery seen in this short-axis cine MR image of same patient shown in B is patch.

View larger version (67K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7D —Complete surgical correction for tetralogy of Fallot. Reformatted 3D shaded surface display MR coronal image of same patient shown in B and C shows enlarged right ventricular outflow tract (star) and pulmonary artery branches in which no significant narrowing or stenosis is visible after complete surgical repair of tetralogy of Fallot. Blue shows right atrium, right ventricle, and pulmonary arteries; and red shows right aortic arch and apex of left ventricle.

View larger version (34K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A —Atrial switch procedure. Sketch of atrial switch procedure. Diagram depicts postoperative status. Systemic venous flow is directed behind baffle into left atrium, through mitral valve, and out pulmonary artery to lungs. Pulmonary venous return is directed over baffle, into right atrium, through tricuspid valve, and out aorta. Gray area highlights left atrial baffle.

View larger version (115K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B —Atrial switch procedure. Axial cine MR image obtained during diastole in 20-year-old man shows how atrial baffle (arrow) of Senning procedure for dextrotransposition of great arteries isolates mitral valve from pulmonary venous drainage. Pulmonary venous blood enters posterior pulmonary venous atrium and flows anteriorly across tricuspid valve (arrowhead). Note thickness of right ventricle wall.

View larger version (152K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8C —Atrial switch procedure. Coronal cine MR image obtained during diastole in same patient shown in B shows that superior (arrowhead) and inferior (arrow) venae cavae drain into systemic venous baffle (star).

View larger version (38K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A —Arterial switch operation (Jatene arterial switch procedure). Anatomic sketch after arterial switch operation (Jatene arterial switch procedure). This procedure consists of removing great vessels from their native ventricles and switching them to contralateral ventricles, with reimplantation of coronary arteries into neoaorta (gray). So-called Lecompte maneuver is performed to bring branch pulmonary arteries from their original posterior position to position anterior to aorta.

View larger version (62K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B —Arterial switch operation (Jatene arterial switch procedure). Reconstructed shaded surface display gadolinium-enhanced 3D MR angiography image shows typical anatomic arrangement of ascending aorta (red) surrounded by pulmonary branches (blue) after Lecompte maneuver arterial switch operation for dextrotransposition of great arteries in 13-year-old girl.

View larger version (84K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9C —Arterial switch operation (Jatene arterial switch procedure). Axial cine MR image of same patient shown in B obtained at level of pulmonary bifurcation during diastole shows full length of patent right and left pulmonary arteries and typical anteroposterior position of pulmonary trunk with respect to ascending aorta.

View larger version (82K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9D —Arterial switch operation (Jatene arterial switch procedure). In this cine MR image of same patient shown in B and C, left and right pulmonary arteries appear to be mildly compressed (arrowheads) at same level as in C but during systole. Nonphysiologic anatomic relationship between ascending aorta and pulmonary branches causes hemodynamic changes in right and left pulmonary arteries. Phase velocity mapping (not shown) did not reveal significant hemodynamic narrowing or stenosis.

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