The utility of cardiac magnetic resonance imaging in post‐Fontan surveillance

Abstract

Objective: Gated cardiac MRI offers the most detailed and accurate noninvasive method of assessing cardiac anatomy, particularly in patients with complex congenital heart disease. The proposed benefits of using cMRI as a routine screening tool in the Fontan population include early recognition of asymptomatic, postoperative anatomic and physiologic changes. In 2011, we therefore instituted at our center a recommended practice of cMRI screening in patients with Fontan physiology at 3 and 8 years post-Fontan operation. The purpose of this study was to determine the impact of this standardized practice of cMRI screening on the clinical management of a Fontan population. Design: We retrospectively reviewed charts from our institutional Fontan database to determine which patients were eligible for cMRI under the current guidelines and who underwent imaging from November 2002 to June 2015. We reviewed the frequency of cMRI and number of changes in management based on the results. Statistical significance was determined using a chi-square test.Results: There were 141 cMRIs performed on 121 patients who met inclusion criteria.The odds of a change in management were significantly greater after clinically indicated cMRI compared to screening cMRI (OR = 3.79, 95% CI: 1.48-9.66, P = .004).There were near significant odds of change in management if the cMRI occurred <8 years after Fontan regardless of whether it was for screening or clinically indicated purposes (OR = 2.43, 95% CI: 0.97-6.08, P = .052). The most frequent change in management was referral for catheterization with pulmonary artery angioplasty. Conclusions:There is an important role for cMRI in routine surveillance of post-Fontan patients. Screening cMRI performed less than 8 years after Fontan palliation offers increased utility compared to studies performed later. The optimal timing of such imaging after Fontan palliation remains unclear. K E Y W O R D Scardiac MRI, Fontan palliation, outcomes, surveillance | 141 ZAKI et al.

Routine surveillance of patients post Fontan palliation: lessons learnt from cardiac catheterisation

“…Similar to MRI observations [1], our findings show limited clinical utility and impact on changing management from routine testing in Fontan patients. However, no definitive conclusion could be drawn based on the small sample.…”

“…Previous studies suggested that these patients present a bimodal pattern, with a cumulative risk of death from thromboembolism increasing during the first 3 years after Fontan palliation and again 15 years after surgery [4,5], reiterating the importance of surveillance. Recent findings indicate that the use of cardiac MRI for post-Fontan surveillance follows this bimodal trend [1], with significantly greater odds of a change in management following clinically indicated MRI after Fontan as compared to screening MRI. We here present complementary observations based on cardiac catheterisation.…”

“…Most Fontan patients reach adulthood [1][2][3]; however, a standardised long-term follow-up strategy has not been agreed, partly reflecting the non-standardised management of these challenging patients across institutions. Fontan patients can develop several complications such as atrial arrhythmias, heart failure, protein losing enteropathy, plastic bronchitis, progressive cyanosis due to veno-venous collateral formation, and Fontan-associated liver disease (FALD), which are the mainstay of Fontan morbidity and mortality [3,4] (Table 1).…”

Institutional transition from invasive to non-invasive imaging in children with univentricular heart defects: safety and cost savings

“…20 All patients at our institution routinely undergo cardiac magnetic resonance examination and peripheral venous pressure measurements prior to the total cavopulmonary connection operation, 1 year after that, and 1-2 times after this throughout childhood and adolescence (see Fig 2). The optimal timing and frequency of posttotal cavopulmonary connection cardiac magnetic resonance studies remain unclear, 21 though the American Heart Association's scientific statement on evaluating a child or adult with a Fontan circulation suggests cardiac magnetic resonance once every 2-3 years. 10…”

Prevalence of Venovenous Shunting and High-Output State Quantified with 4D Flow MRI in Patients with Fontan Circulation

“…Previous retrospective surveys of MRI analysis in pediatric patients showed benefit of routine MRI to alter and benefit clinical management (22) and modest correlation of the degree of systemic-to-pulmonary venous collateral flow to ventricular volume loading, central venous pressure, serum brain (or b-type) natriuretic peptide, and poor functional class (23). Perhaps most closely related to the current work is a prior observation that decreased caval return via the Fontan circuit had the strongest correlation to poor clinical condition and age (24).…”