title: Direct en face imaging of secundum atrial septal defects by velocity-encoded cardiovascular magnetic resonance in patients evaluated for possible transcatheter closure.
abstract: BACKGROUND
  Atrial septal defect (ASD) flow can be measured indirectly by velocity-encoded cardiovascular magnetic resonance (veCMR) of the pulmonary artery and aorta. Imaging the secundum ASD en face could potentially enable direct flow measurement and provide valuable information about ASD size, shape, location, and proximity to other structures.
  
  
  RESULTS
  Forty-four patients referred for possible transcatheter ASD closure underwent a comprehensive standard evaluation, including transesophageal and/or intracardiac echocardiography and invasive oximetry. CMR was performed in parallel and included direct en face veCMR after an optimal double-oblique imaging plane was determined that accounted for ASD flow direction and cardiac-cycle interatrial septal motion. ASD flow measured by direct en face veCMR correlated better with invasive oximetry than indirect (pulmonary artery and aorta) veCMR (r=0.80 versus r=0.66). Additionally, 95% limits of agreement were narrower (+/-3.9 versus +/-5.1 L/min). En face veCMR determined that defects usually were eccentrically shaped (major/minor axis length >1.5) rather than circular, with 16% having extreme eccentricity (major/minor >2.0). Overall, ASD size by both veCMR and intracardiac echocardiography correlated with final device size; however, in small to medium defects (<3 cm(2)) and extremely eccentric defects, veCMR correlated better with final device size than did intracardiac echocardiography. Importantly, CMR identified additional information in 9 patients (20%) that altered clinical management. Specifically, en face veCMR detected additional defects (n=3), large ASD with insufficient rim tissue (n=2), and sinus venosus defect with anomalous pulmonary vein (n=1). Cine and/or morphological imaging detected interrupted inferior vena cava (n=2) and sinus of Valsalva aneurysm (n=1).
  
  
  CONCLUSIONS
  En face veCMR with an optimized imaging plane can determine ASD flow, size, and morphology. CMR provided information incremental to comprehensive standard evaluation that altered clinical management in 20% of patients.
authors.affiliation: Duke Cardiovascular Magnetic Resonance Center, Duke University Medical Center, Durham, NC 27710, USA.
authors.forename: Louise E J
authors.initials: LE
authors.lastname: Thomson
authors.forename: Anna Lisa
authors.initials: AL
authors.lastname: Crowley
authors.forename: John F
authors.initials: JF
authors.lastname: Heitner
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Cawley
authors.forename: Jonathan W
authors.initials: JW
authors.lastname: Weinsaft
authors.forename: Han W
authors.initials: HW
authors.lastname: Kim
authors.forename: Michele
authors.initials: M
authors.lastname: Parker
authors.forename: Robert M
authors.initials: RM
authors.lastname: Judd
authors.forename: J Kevin
authors.initials: JK
authors.lastname: Harrison
authors.forename: Raymond J
authors.initials: RJ
authors.lastname: Kim
mesh_terms: D000328:Adult; D000368:Aged; D054087:Atrial Septum / Q000000981:diagnostic imaging / Q000473:pathology* / Q000503:physiopathology; D006328:Cardiac Catheterization / Q000295:instrumentation; D017548:Echocardiography, Transesophageal; D004867:Equipment Design; D005260:Female; D006344:Heart Septal Defects, Atrial / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy; D006439:Hemodynamics; D006801:Humans; D019028:Magnetic Resonance Imaging, Cine; D008297:Male; D008875:Middle Aged; D010092:Oximetry; D018579:Patient Selection; D011237:Predictive Value of Tests; D012720:Severity of Illness Index; D016896:Treatment Outcome; D055815:Young Adult