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The right ventricle under stress: CMR of the Pressure/Volume Overloaded RV

Non-invasive Imaging: Magnetic Resonance Imaging

This well attended session took place early Friday morning.  Five experienced physicians discussed the impact that magnetic resonance imaging of the right ventricle has on the treatment and prognosis of individuals with congenital heart disease.

Dr. Shahin Moedina (Great Ormand Street Hospital) began the discussion addressing some of the challenges of assessing the right ventricle in children in the setting of pulmonary hypertension.  He noted that imaging of the right ventricle in the paediatric population is difficult given the frequent breath holds required for imaging acquisition.  This has led to the development of a high spatial and temporal resolution free breathing real-time sequence with volumetric accuracy similar to traditional EKG and breath hold methods.  He went on to emphasise that right ventricular ejection fraction has become a strong prognostic marker in the paediatric population, especially when associated with adverse remodelling due to a high afterload state.   In addition, assessment of septal curvature may be used in the future for screening of worsening pulmonary hypertension.

Next up included one of the moderators, Dr. Krishnamurthy (Texas Children’s Hospital) who presented information on the right ventricle in the setting of single ventricle.  Initially, he made the point that despite improvements in surgical repair of the single ventricle using the Fontan procedure that late mortality has not changed as much as expected.  The thought is that ventricular remodelling and regional/global biomechanics are much worse in the single ventricle setting.  Specifically, he discussed ventricular strain and torsion models as well as giving real-world examples to support this thought.

Following this, Dr. Philipp Beerbaum (Hanover Medical University) spoke about a problem that adult cardiologists may encounter – that of the overloaded right ventricle in the setting of repaired Tetrology of Fallot.  These patients tend to develop right ventricular dysfunction due to chronic severe pulmonic regurgitation that results in right ventricular scarring and associated arrhythmia.  Poor prognostic signs include a right ventricular mass to volume ratio greater or equal to 0.3 and negative impact on the left ventricular ejection fraction.  The timing of pulmonic valve replacement is critical and this is where cardiac imaging can be helpful.  On the horizon, elements such as right ventricular function during stress, regional left ventricular dysfunction despite a normal LVEF, and gender specific remodelling features are being closely considered and revisited.

Sohrab Fratz, MD (German Heart Centre Munich) compared and contrasted the overloaded right ventricle in the setting of Ebstein Anomaly.  Dr. Fratz emphasised the importance of axial cine image acquisition in the qualitative volume assessment of the right ventricle due to the significant reduction in intra and inter-observer variation over short axis cine sequences.  He noted that despite traditional thought, the functional right ventricle is actually larger in volume prior to Ebstein repair and that this volume reduces over time in the repaired heart.  Although the right ventricular ejection fraction improves in most cases, occasionally this does not occur.  The thought is that during the surgery the moderator band is removed resulting in an increased end diastolic volume and actual worsening of systolic function.

Claudio Capelli, PhD (University College London) concluded the session with a talk on the role of CMR in the planning of pulmonic valve replacement.  He demonstrated the utility of 3-D imaging of the right ventricular outflow tract and main pulmonary artery to develop models to tailor percutaneous pulmonary valves.  These models are also used for procedural and fluid structure simulation in order to select the best method of valvular replacement.  Through his work, Dr. Capelli has developed an extensive database of 3-D models for future development of percutaneous valves.
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.