interventional cmr: how i use my combination mr/cath suite? · evaluation of interstage physiology...

Interventional CMR: How I use my combination MR/Cath Suite?

Suren V. Reddy, MD/FSCAIAssociate Professor of Pediatrics

Interventional Cardiology and Adult Congenital Heart Disease

University of Texas Southwestern Medical Center &

Children’s Health – Dallas Texas

The 15th SPR Advanced Symposium On Pediatric Cardiovascular Imaging International Symposium on 3D Imaging for Interventional Catheterization in CHD

October 19th, 2019 – Columbus Ohio

Disclosure

• Just a Cath doctor with tools!

• No official MRI training.

• Research reported in this presentation was supported by the Moss Foundation and CCRAC-Children’s Health, Dallas.

Outline

• Background - Dallas Infrastructure

• Brief overview of pts so far

• Use combination MR/Cath Suite?• Why?• Who?

• Single ventricle patient evaluations• Two ventricle patient evaluations

• How? Case examples

• Limitations

• Conclusions and Future Directions

GadoliniumContrast

MRI alone

Catheteralone

Catheter + MRI

Volume X X

Flow X X

Cardiac output X X X

Pressure X X

PVR X X

Anatomy X X X

Preload X

Systolic function X X X

Diastolic function

X X

Afterload & coupling

X

Work X

Interventional Cardiac Magnetic Resonance (iCMR)Cath + MRI = iCMR “One Stop Shop”

(iCMR = Hybrid MRI-Cath = MRI guided Cath = CMR fluoroscopy catheterization)

Courtesy – Dr. James Wong, KCl/Evelina, London

MRWire Basics

MRI Compatible (Nano4Imaging)

Sagittal view: Desc Ao

Dallas ICMR Infrastructure

Hybrid Catheterization Philips AlluraClarity System

iCMR Suite Phillips Ingenia 1.5 Tesla

Single Ventriclen = 35

Biventricularn = 15

Fontann = 16

Non-fenestratedn = 6

Fenestrationn = 10

Pre-Fontann = 18

Coarctationn = 4

Nitric testingn = 5

TOFn = 3

s/p OHTn = 1

PA stenosisn = 2

Total Patientsn = 50

Dallas iCMR: Patient Characteristics

Pre-Glennn = 1

08/01/2017 – 08/10/2019

Dallas iCMR: Patient Characteristics

Patient demographics

• Sex (%) = 66% male (n = 27)

• Age (years) = 7.9 (range 0.25 - 33)

• Weight (kg) = 26.0 (range 7.6 - 80)

• Single Ventricle (%) = 70%

• No catheter related complications

• Complications, n = 1 (arrhythmia)


Biventricularn = 15


08/01/2017 – 08/10/2019

iCMR procedure = 103 minsRHC = 5.4 minsLHC = 2.6 mins

iCMR procedure = 114 minsRHC = 5.2 minsLHC = 3.1 mins

Single Ventricle22/35 = 63%

Biventricular7/15 = 47%

Fontan8/16 = 50%

Non-fenestrated2/6 = 33%

Fenestration6/10 = 60%

Pre-Fontan14/18 = 78%

Coarctation4/4 = 100%

Nitric testing0/5 = 0%

TOF2/3 = 66%

s/p OHT1/1 = 100%

PA stenosis0/2 = 0%

Total Patients29/50 = 58%

iCMR Cath Lab Transfer

Pre-Glenn0/1 = 0%

08/01/2017 – 08/10/20191V 2V Total

2017 1/2 1/3 2/5

2018 16/19 6/10 22/29

2019 5/14 0/2 5/16

1V 2V Total

Coils 13 0 13

CoA Stents 0 4 4

FFDC 3 0 3

Diagnostic 3 0 3

Angioplasty 1 1 2

PA Stent 1 1 2

FFTO 1 0 1

Biopsy 0 1 1

Transfer to cath lab / Total patients

MR guidewire Experience in CHD

• SVC and left innominate vein (complex anatomy patients)

• Left atrium across PFO

• Left ventricle, retrograde

• Stenotic branch PAs

• Branch PAs in transannular patch with free pulmonary insufficiency

• Cross severely stenotic RV-PA conduit

• Aortic obstruction/Coarctation



Biventricularn = 15

• Bilateral pulmonary veins

• Transhepatic wedge pressures

• Stenotic branch PAs in Glenn and Fontan pts

• Fontan fenestration – for fenestration test occlusion

• Left ventricle, retrograde

iCMR Total, n = 50MRWire Total, n = 40 08/01/2017 – 08/08/2019

ICMR

Single Ventricle pts 2 Ventricle pts

How I use my combination MR/Cath Suite?

ICMR

Single Ventricle pts

Blue Glenn, Pre-Fontan Eval

Blue Fontan, FFTO Eval

Failing Fontan, PreTransplant

Eval


Hemodynamics+Anatomy+Volumetric/Function+Lymphatic data all at the same time)

• Blue Glenn evaluation

• Pre Fontan

• Post Fontan (Blue Fontan, failing Fontan evaluation)

• Fontan fenestration test occlusion (FFTO)

ICMR – Single Ventricle Evaluation - One Stop Shop!!

• Pressures and anatomy at same time – same preload and afterload

• Detailed RHC, LHC – feasible to do detailed eval with MRI guidewire

• Accurate Qp/Qs and PVR eval

• iNO testing as needed

• Relative branch PA flows – help decide candidacy for intervention

• 3 D anatomical information of PAs/Glenn pathway, aortic arch (use for overlay/Xray fusion)

• Unusual decompressing venous collaterals to azygous and hemiazygoussystem

• AP collateral flow quantification

• Assess lymphatics – risks stratification

• Selective PA angiography for identification of pulmonary AVMs in MRI

1. ICMR Pre-Fontan evaluation

2. ICMR Fontan failure evaluation

3. ICMR Fontan Fenestration Test Occlusion

Single Ventricle Case Examples

MRI FlowsQp/Qs

RHC/LHC(Fick Qp/Qs)

Single VentriclePre-Fontan Evaluation

LymphaticsAbnormalities

3 D Anatomy

& Function

Case 1 - PreFontan RHC/LHC EmeryGlide Wire used for LA and LPA access

• 4 yrs old, 15.4 ks, HLHS s/p Norwood/Sano and Glenn

• Indication – PreFontan Cath/MRI

• Access RFV/RIJV/RFA

• 100% catheter visualization – Yes

• First pass RHC – 4 mins

• First pass LHC/aortic pull back 2 mins

• MRWire used – LA access, LPA

• Complications – none

• 30% collateral flow – transferred to lab, coiled collaterals

Pre-Fontan LHC and Aortic angiography

Glenn Pathway Eval – I Suite Overlay Imaging

60

ICMR “bubble study”Pulmonary AVMs

60 mm slice thickness; 250 ms/image(4 fps)

iCMR Lymphatic Insufficiency EvaluationT2W-MRL DCMRL Trans-catheter Intervention

iCMR SV T2W-MRLn = 16

Type 1n = 5

Type 3n = 4

Type 4n = 3

Type 2n = 4

High Risk ± DCMRLn = 4

± TranscathaterIntervention

n = 3

Observe

Low/MedRisk

3D-DCMRL Evaluation (Type 4)DCMRL Evaluation (Type 3)


Liver Failure

Diastolic Failure

SystolicFailure Pulmonary HTN

ArrhythmiasAP collateralsExercise intoleranceFontan revisionsRestrictive lung dzCyanosisVV collateralsFenestration issuesStrokeNephrolithiasis2/2 hyperPTH

Fontan Failure Phenotypes

Fontan CirculationSyndrome:

Systemic venous HTN + low CO

iCMR Fontan Protocol

Lymphatic Failure

Access (Femoral

artery/vein ± IJV ± lymph node access for DCMRL)

Survey, MV flow, 3D Whole Heart, Vista,

3DSSFP, Flows, T2W-MRL

Fontan/RHC + Liver Wedge

Retrograde LHC T2W-MRL

DCMRL

Fontan Assoc.Liver

Disease Hepatic Wedge

Elastography

Qp & Qs

(Fick/Flow)iCMR FFTO

Zone 3

Zone 4

Fenestrated Fontan

3D-bSSFPType 1-2

No lymphatic Intervention

Type 3-4Consider lymphatic

Intervention

1. Anatomically unobstructed

Fontan pathway with no

significant decompressing

venovenous collaterals;

2. Baseline Fontan pressure ≤

15 mmHg;

3. Baseline cardiac index ≥ 2

L/min/m2;

4. Decrease in cardiac index ≤

20% from baseline with test

occlusion of the Fontan

fenestration.

No closure recommended

Transfer to cath lab for

closure

YesNo

Dynamic Contrast MR Lymphangiography

(DCMRL)

SystolicFailure

Diastolic Failure

Vent Function

Qs

Chamber size

EDP


Liver Failure

Diastolic Failure

SystolicFailure

Fontan Failure Phenotypes

Fontan CirculationSyndrome:

Systemic venous HTN + low CO

ElastogramColor Map

iCMR Fontan Fenestration Test Occlusion (FFTO)

Red Arrow = Gadolinium-filled balloon; Green Arrow = MRWire

Fenestration Shunting R L

Step 1

Step 2

Step 3

iCMR EvalFick + Flow

iCMR: Fontan Test Occlusion

Cath lab: ASO Device Closure

93% 97%

1313 0.9

+ Ventricular EDP+ Lymph DCMRL + Elastography

(Liver/Spleen)+ AP/VV Collaterals+ Ventricular volumes

One Stop Shop

iCMR Fontan, n = 9

Case 3 – Fontan fenestration test occlusion

• 7 yrs old, 22 kgs, Tri atresia s/p extracardiac Fen Fontan

• Normal Fontan pressures (12-13 mm Hg)

• Successful FFTO performed in the MRI Suite

• No change in Fontan pressures or Cardiac output

• Small increase in branch PA flows

• Fontan fenestration device closure (4 mm ASO) in Cath lab

Confirmation of Gad filled balloon across Fontan fenestration

MRWire accessing Fontan fenestration

I Suite – Overlay images showing Fontan Fenestration Test Occlusion (FFTO)

ICMR

2 Ventricle pts

Multiple shunts (ASD+VSD+PDA)

Pulmonary HTN

Coarctation of aorta +/- arch

hypoplasia

RV-PA conduits, Branch PA stenosis


ICMR – Two ventricle evaluation - One stop shop!!Hemodynamics+Anatomy+Volumetric/Function data + iNO testing, Overlay for interventions in cath suite

• Multiple shunts - accurate Qp/Qs and PVR evaluation to decide candidacy for repair • Cath based pressures and anatomy at same time – same preload and afterload• 3 D anatomical information • iNO testing as needed

• Pulmonary hypertension patients • Accurate flows and PVR • Relative PA flows

• Coarctation of aorta with suspected transverse arch hypoplasia• MRI rules out transverse arch hypoplasia• Cath measured gradient• Overlay/fusion of MRI – for cath lab intervention

• RV-PA conduits/valve dysfunction, branch PA stenosis • RV pressures• Branch PA gradients + relative PA flows at same time – aids in accurate decision

making for interventions

1. Coarctation of aorta – aortic arch hypoplasia?

2. TOF repair – RV-PA conduit stenosis

Two Ventricle Case Examples

Case 1: CoA +/- arch hypoplasiaMRI guidewire use to cross CoA

• 5 yrs old, 18.5 kgs

• Severe CoA and suspected transverse arch hypoplasia

• Referred for MRI to decide candidacy for Cath or Surgical intervention

• Offered Combined MRI-Cath procedure

• Access - RFV, RFA

• First pass RHC – 3 mins, First pass LHC 2 mins, 49 mm Hg gradient

• MRWire - used to access the arch across severe CoA• LV could not be reached due to geometry of arch (BiAV)

• iCMR – Trivial arch hypoplasia, severe CoA

• Cath lab – Covered CP stent dilation CoA access with MRWire

ICMR

Single Ventricles

Blue Glenn and Pre-

Fontan Eval

Blue Fontan, FFTO Eval

Failing Fontan, PreTransplant

Eval

2 Ventricles

Multiple shunts

(ASD+VSD+PDA)

Pulmonary

HTN

RV-PA conduits, Branch PA stenosis

Coarctation of aorta +/- Arch

hypoplasia


Potential Pitfalls & Future Directions

• Next step: • MRI compatible access kit

• Next interventions: • Valve/Vessel balloon –plasty

• Device testing: • Fontan fenestration closure

• Collaborations: • Radiology, Cardiology,

Gastroenterology, etc.

• Future: • Split BORE magnet

• Inconsistent image: • Gadolinium Phantom

• MRI safe devices:• Industry collaboration

• Anesthesia times:• Fewer induction

• Cath physician buy-in• No radiation

Conclusions

• Newer ICMR techniques and availability of the MRI compatible guidewire • enables thorough RHC & LHC procedures in complex CHD patients.

• ICMR evaluation provides a more complete, accurate and reproducible evaluation of interstage physiology especially important in the failing Fontan patient.

• One stop shop to fully assess our single ventricle patients.

• ICMR is a promising alternative for children and adults with CHD• Radiation sparing and incremental value with anatomical and physiological data• May help with better risk stratification and management of CHD patients (Single

ventricles)• Enhances conventional interventional procedures – fusion/overlay, lymphatic

occlusion procedures

Many Thanks to the Entire Heart Center TeamDr. Tarique Hussain Dr. Gerald Greil Maggie and

Cath lab team Dr. Yousef Arar Cards fellow

Ms. Amanda Potersnak

Dr. Jenn Hernandez

Dr. Daniel Castellanos CMR fellow

Joshua Greer Ph.DCMR Physicist

Questions?Retrograde LHC

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