MRT der Pulmonalarterien bei Kindern nach arterieller Switch-Operation (ASO) bei Transposition der großen Gefäße (d-TGA)

Zusammenfassung

Ziel: Untersuchung zur Wertigkeit der MRT in der Verlaufskontrolle bei Patienten mit d-TGA nach Switch-Operation. Material und Methoden: 14 konsekutive Patienten (Alter 4 bis 20 Jahre, Durchschnitt 13,5) nach arterieller Switch-Operation (ASO) bei Dextro-Transposition der großen Gefäße (d-TGA) wurden bei unzureichendem echokardiographischen Schallfenster mit der MRT untersucht. 9 Patienten hatten eine ASO mit der Pulmonalarterienbifurkation vor der Aortenwurzel (Kollektiv 1), 5 Patienten eine ASO mit lateral (2 links, 3 rechts) der Aortenwurzel gelegener Pulmonalarterienbifurkation (Kollektiv 2) erhalten. Die MRT erfolgte bei 6 Patienten mit kontrastangehobenen MR-Angiographien der pulmonalen Strombahn, 8 Patienten erhielten Nativuntersuchungen der Pulmonalarterien. Die Messungen der Gefäßdiameter der Pulmonalarterien erfolgten direkt an der Pulmonalarterienbifurkation sowie an 2 weiteren Messpunkten jeweils im Abstand von 1 cm in zwei Ebenen. Ergebnisse: Ein Patient wies eine hochgradige supravalvuläre Pulmonalarterienstenose mit nachfolgendem Aneurysma auf. Echokardiographisch ergaben sich bei diesem Patienten nur indirekte Hinweise auf eine Pulmonalarterienstenose. Bei allen anderen Patienten fanden sich regelrechte Pulmonalarterienhauptstämme ohne Stenosen. Die Pulmonalarterien des Kollektivs 2 fielen im Vergleich zum Kollektiv 1 MR-tomographisch insgesamt etwas weiter aus. Diejenige Pulmonalarterie, welche bei lateral gelegener Pulmonalarterienbifurkation den Aortenbogen unterkreuzte, wies regelhaft im Seitenvergleich ein reduziertes Kaliber auf. Im Kollektiv 1 war regelhaft die linke Pulmonalarterie im Vergleich zur rechten kaliberschwächer. Bemerkenswert war, dass Einengungen der Pulmonalarterien mit Ausbildung eines ovalären Gefäßlumens einhergingen. Schlussfolgerung: Einengungen der Pulmonalarterien gehen nach ASO mit ovalären Gefäßdiametern einher, weshalb eine multiplanare bildgebende Diagnostik erforderlich scheint. Die MRT erfüllt diese Anforderungen und weist somit Vorteile gegenüber der Echokardiographie auf. Eine diagnostische Angiographie sollte nur in Interventionsbereitschaft erfolgen.

Abstract

Purpose: To determine the value of MRI in postoperative evaluation of patients with arterial-switch-operation (ASO) for d-TGA. Material and Methods: 14 consecutive patients with d-TGA and ASO were examined with MRI in addition to ultrasound because the acoustic window in echocardiography was insufficient. Nine patients had a pulmonary-artery-bifurcation anterior to the aortic root (group 1), and five (group 2) laterally (two of them left, three of them right). MRI was performed in six patients as contrast-enhanced MR-angiography, in 8 patients as native examination. Diameters of pulmonary arteries were measured in two perpendicular views at the origin and in two further locations each with a distance of one cm. Results: One patient showed a supravalvular pulmonary artery stenosis with subsequent pulmonary artery aneurysm, which had not been detected in echocardiography. This patient showed only indirect signs of pulmonary artery stenosis in echocardiography. Compared to group 1, pulmonary arteries in group 2 generally had greater diameters. Those pulmonary arteries in Group 2 which cross the mediastinum underneath the aortic arch had lower diameters compared to the pulmonary artery positioned on the other side. In group 1, the left-sided pulmonary artery had lower diameters than the right-sided pulmonary arteries. It seems remarkable that the narrowing of pulmonary arteries is associated with a flattening of the transversal vessel diameter. Conclusion: Narrowing of pulmonary arteries after ASO is associated with oval vessel diameters. Therefore, multiplanar diagnostic methods are necessary. MRI meets this prerequisite and is therefore advantageous to echocardiography in follow-up examinations at patients with ASO for d-TGA. Special attention should be focused on the main pulmonary artery, on the left pulmonary artery in patients with preaortic pulmonary artery bifurcation as well as on the pulmonary artery which crosses the mediastinum in patients with laterally placed pulmonary artery bifurcation. Angiography should only be performed when intervention is planned.

Key words

Congenital heart disease - MRI - d-TGA - arterial switch operation

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