Attention ASE Members:
The ASE has gone green! Visit www.aseuniversity.org to earn free continuing medical education credit through an online activity related to this article. Certificates are available for immediate access upon successful completion of the activity. Nonmembers will need to join the ASE to access this great member benefit!
1
Executive Summary
Advances in the diagnosis and management of congenital heart disease (CHD) have led to a marked improvement in the survival of patients with tetralogy of Fallot (TOF). However, residual anatomic and hemodynamic abnormalities are common. As with other types of congenital and acquired heart diseases, diagnostic information in patients with repaired TOF can be obtained using a variety of diagnostic tools. The choice of when to perform echocardiography, cardiovascular magnetic resonance (CMR) imaging, computed tomography (CT), nuclear scintigraphy, diagnostic catheterization, or a combination of these diagnostic procedures is dictated by the clinical question(s) asked and by a host of factors related to the patient, the modality, and the clinical circumstances. The aims of this document are to describe the role of each diagnostic modality in the care of patients with repaired TOF and to provide guidelines for a multimodality approach that takes into account patient-related and modality-related considerations.
Goals of Imaging
The overarching goals of diagnostic imaging are to identify anatomic and functional abnormalities, assess their severity, and provide information that informs clinical decisions. A list of essential data elements required for optimal management is summarized in section 4.
Imaging Modalities
In the following sections, each of the imaging modalities used for the evaluation of patients with repaired TOF is reviewed, and the strengths, weaknesses, and clinical utility of each modality are discussed. Finally, we propose an integrated multimodality imaging approach in this group of patients.
Echocardiography
Two-dimensional (2D) and Doppler echocardiography allow the evaluation of many of the anatomic and hemodynamic abnormalities in patients with repaired TOF. This modality is relatively inexpensive, widely available, not associated with exposure to harmful ionizing radiation, and portable. Therefore, echocardiography is ideally suited for longitudinal follow-up in this group of patients. Important limitations of the modality include difficulties in visualizing certain parts of the right heart because of restricted acoustic windows and challenges in quantitative assessment of right ventricular (RV) size and function and valve regurgitation.
CMR
CMR is considered the reference standard for the quantification of RV size and function and pulmonary regurgitation (PR) in patients with repaired TOF. The modality is ideally suited for longitudinal follow-up in this population because it allows comprehensive assessment of cardiovascular morphology and physiology without most of the limitations that hinder alternative imaging modalities. CMR is used selectively during the first decade of life, assuming a routine role in older patients.
Cardiovascular CT
Advances in multidetector computed tomographic technology have led to improvements in both spatial and temporal resolutions. Multidetector CT (MDCT) is used in patients with repaired TOF in whom CMR is contraindicated or unavailable.
Nuclear Scintigraphy
In current practice, the primary use of nuclear imaging in patients with repaired TOF is to measure pulmonary perfusion.
X-Ray Angiography
Diagnostic cardiac catheterization is rarely used primarily for imaging purposes in patients with repaired TOF. However, it serves an important role when essential information cannot be accurately obtained noninvasively. Additionally, x-ray angiography is an integral component of catheter-based procedures such as pulmonary artery (PA) balloon dilation and stenting and percutaneous pulmonary valve (PV) implantation. In adult patients at risk for acquired coronary artery disease, coronary angiography may be indicated.
Multimodality Imaging
No single modality is able to delineate all aspects of the intracardiac and extracardiac anatomy, evaluate hemodynamic consequences of TOF repair, be cost effective, reach patients in various locations, not cause excessive discomfort and morbidity, and not expose patients to harmful effects of ionizing radiation. Therefore, a multimodality approach that takes into account patient-specific considerations, strengths and weaknesses of each modality, and institutional resources and expertise is recommended.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
