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DOI: 10.1055/s-0036-1584513
3D Heart Model and 4D Flow MRI 20 Years after Spiral Arterial Switch Operation
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Publication History
04 March 2016
01 May 2016
Publication Date:
21 June 2016 (online)
Abstract
Case of a patient is presented here 20 years after spiral direct anastomosis of the great arteries in an arterial switch operation. Three-dimensional model of the heart combined with four-dimensional flow magnetic resonance imaging presents a novel comprehensive way to assess surgical results.
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Keywords
transposition of great arteries - magnetic resonance imaging - physiological spiral anastomosisIntroduction
The first successful arterial repair for transposition of the great arteries (TGAs) was performed in 1975 by Jatene et al using a direct spiral anastomosis of the great arteries.[1] In 1981, the Lecompte et al technique, characterized by transposition of the pulmonary artery (PA) bifurcation in front of the ascending aorta, was introduced with excellent short-term results.[2] Nevertheless, this unphysiological anatomy is reported to contribute to dilatation of the ascending aorta proximal to the pulmonary bifurcation, progressive aortic regurgitation, steep angled aortic arch, and most commonly pulmonary stenosis.[3] [4] Little is known about the physiological spiral anastomosis of the great arteries as an alternative switch operation especially after somatic growth. We present morphology through a three-dimensional heart model and four-dimensional (4D) flow magnetic resonance imaging (MRI) in such a case.
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Case Description
In 1991, a 2-day-old newborn male with simple TGA, normal coronary artery pattern (1L-2RCx), and an intermediate position of the great arteries (aortic root to pulmonary root between anterior–posterior and side-by-side position) underwent the arterial switch operation using spiral anastomoses of the great arteries and a pantaloon patch of untreated autologous pericardium to fill the coronary button holes and to extend the short main PA for 1.0 cm ([Fig. 1]). In 2012, the patient underwent invasive catheterization showing a mild pulmonary stenosis (i.e., maximum gradient of 20 mm Hg) with normal function of semilunar valves. In 2015, a 3D model of his heart was developed out of polyurethane according to phase-contrast cardiac MRI data ([Fig. 2]: MR voxel size 1.12 × 1.11 × 7 mm; [Fig. 3]: 3D model pixel size 0.66 × 0.66 mm, layer size 1 mm) with a resolution of ± 0.3% and a layer thickness of 0.12 mm (Materialise GmbH, Gilching, Germany). At follow-up, the neopulmonary root was found to have spontaneously rotated from a preoperative rightward position to the left, and the physiological spiral anatomy of the great arteries and physiological blood flow were restored ([Fig. 2]). A mild narrowing of the right PA behind the aorta ([Fig. 2A]) was discovered. In [Fig. 3], the position of the left coronary artery between the neoaortic root and the neopulmonary root is shown as well as the pulmonary bifurcation in a cross-section. First pass myocardial perfusion MRI at rest and during stress confirmed a homogenous microcirculation of the left ventricle.
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Discussion
The 3D heart model nicely shows the physiological spiral relations of the great arteries. Flow streamlines throughout the pulmonary and aortic outflow tracts were found parallel in a spiral fashion and apart from each other ([Fig. 2C]). The spontaneous rotation of the neopulmonary root to a leftward position was an unexpected finding and may probably indicate some morphological plasticity during growth. The right PA seems to be under some tension, which may have been improved if the distal PA anastomosis was performed somewhat into the left PA to gain some length for the right PA. The left anterior descending coronary artery was not found to be under compression. No significant stenosis was found at the area of the pericardial pantaloon tube patch confirming that fresh autologous pericardium is an appropriate material for PA patch plastics during arterial switch operation, as suggested by Paillole et al.[5]
We conclude that 3D heart models combined with 4D flow MRI are excellent means to assess the surgical results and visualize the spatial relationships of the anatomical structures.
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Acknowledgments
The authors are grateful to Mrs. Traudel Hansen for her assistance in patient management and Mr. Michael Diwoky for his support in preparation of this report.
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References
- 1 Jatene AD, Fontes VF, Paulista PP , et al. Successful anatomic correction of transposition of the great vessels. A preliminary report. Arq Bras Cardiol 1975; 28 (4) 461-464
- 2 Lecompte Y, Zannini L, Hazan E , et al. Anatomic correction of transposition of the great arteries. J Thorac Cardiovasc Surg 1981; 82 (4) 629-631
- 3 Losay J, Touchot A, Capderou A , et al. Aortic valve regurgitation after arterial switch operation for transposition of the great arteries: incidence, risk factors, and outcome. J Am Coll Cardiol 2006; 47 (10) 2057-2062
- 4 Rickers C, Kheradvar A, Sievers HH , et al. Is the Lecompte technique the last word on transposition of the great arteries repair for all patients? A magnetic resonance imaging study including a spiral technique two decades postoperatively. Interact Cardiovasc Thorac Surg 2016; 22 (6) 817-825
- 5 Paillole C, Sidi D, Kachaner J , et al. Fate of pulmonary artery after anatomic correction of simple transposition of great arteries in newborn infants. Circulation 1988; 78 (4) 870-876
Address for correspondence
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References
- 1 Jatene AD, Fontes VF, Paulista PP , et al. Successful anatomic correction of transposition of the great vessels. A preliminary report. Arq Bras Cardiol 1975; 28 (4) 461-464
- 2 Lecompte Y, Zannini L, Hazan E , et al. Anatomic correction of transposition of the great arteries. J Thorac Cardiovasc Surg 1981; 82 (4) 629-631
- 3 Losay J, Touchot A, Capderou A , et al. Aortic valve regurgitation after arterial switch operation for transposition of the great arteries: incidence, risk factors, and outcome. J Am Coll Cardiol 2006; 47 (10) 2057-2062
- 4 Rickers C, Kheradvar A, Sievers HH , et al. Is the Lecompte technique the last word on transposition of the great arteries repair for all patients? A magnetic resonance imaging study including a spiral technique two decades postoperatively. Interact Cardiovasc Thorac Surg 2016; 22 (6) 817-825
- 5 Paillole C, Sidi D, Kachaner J , et al. Fate of pulmonary artery after anatomic correction of simple transposition of great arteries in newborn infants. Circulation 1988; 78 (4) 870-876