CT and MRI in Congenital Heart Diseases

Foreword
Preface
Contents
About the Editors and Contributors
	About the Editors
	Contributors
Part I: The Basics of CHD imaging
	1: CMR Physics
		1.1	 Introduction
		1.2	 Hardware
			1.2.1	 Magnets
			1.2.2	 Coils
		1.3	 Principle
		1.4	 MR Signal Formation
			1.4.1	 Radio-frequency Excitation
			1.4.2	 180° and 90° Pulse
			1.4.3	 T1 Relaxation/Spin: Lattice Relaxation
			1.4.4	 T2 Decay or Spin: Spin Relaxation
			1.4.5	 T2* Relaxation
		1.5	 MR Signal Localization
			1.5.1	 Slice Selection
			1.5.2	 Phase Encoding
			1.5.3	 Frequency Encoding
			1.5.4	 k-Space
			1.5.5	 Scan Time
		1.6	 Sequences
			1.6.1	 Spin-Echo (SE) Imaging
			1.6.2	 Gradient-Echo (GRE) Imaging
			1.6.3	 Parallel Imaging
			1.6.4	 Myocardial Tagging
			1.6.5	 Contrast-Enhanced (CE) Imaging
			1.6.6	 Mapping Sequences
		1.7	 ECG Gating
		1.8	 MR Artifacts
			1.8.1	 Equipment-Related Artifacts
			1.8.2	 Aliasing or Wrap-Around Artifact
			1.8.3	 Aliasing During Flow Analysis
			1.8.4	 Chemical Shift Artifact
			1.8.5	 Truncation or Gibbs Artifact or Dark Rim Artifact
			1.8.6	 Magnetic Susceptibility Artifact
			1.8.7	 Trigger Artifact
			1.8.8	 Blood Flow Artifact
		1.9	 Conclusion
		References
	2: Cardiac Embryology
		2.1	 Introduction
		2.2	 Early Embryonic Development
		2.3	 Cardiac Development
			2.3.1	 Formation of the Endocardial Tube
				2.3.1.1	 Clinical Correlate
		2.4	 Determination of Right-Left Symmetry
			2.4.1	 Clinical Correlate
		2.5	 Formation of the Myocardium
			2.5.1	 Clinical Correlate
		2.6	 Formation of the Four-Chambered Heart
		2.7	 Formation of the Right and Left Atrioventricular Canals
			2.7.1	 Clinical Correlate
		2.8	 Formation of the Interventricular Septum (IVS)
			2.8.1	 Clinical Correlate
		2.9	 Formation of the Interatrial Septum
			2.9.1	 Clinical Correlates
		2.10	 Separation of the Outflow Tracts
			2.10.1	 Clinical Correlate
				2.10.1.1	 Conotruncal Anomalies
				2.10.1.2	 Truncus Arteriosus
				2.10.1.3	 D: Transposition of the Great Arteries
				2.10.1.4	 Tetralogy of Fallot (TOF)
				2.10.1.5	 Double Outlet Right Ventricle (DORV)
		2.11	 Development of the Aortic Arches and the Great Vessels
			2.11.1	 Clinical Correlate
				2.11.1.1	 Double Aortic Arch
				2.11.1.2	 Right Aortic Arch
				2.11.1.3	 Aberrant Right Subclavian Artery
				2.11.1.4	 Interruption of the Aortic Arch
				2.11.1.5	 Patent Ductus Arteriosus (PDA)
				2.11.1.6	 Coarctation of the Aorta
		2.12	 Formation of the Venous System
			2.12.1	 Clinical Correlate
				2.12.1.1	 Persistent Left Superior Vena Cava
				2.12.1.2	 Isolated Left Superior Vena Cava
				2.12.1.3	 Azygous Continuation of the Inferior Vena Cava
				2.12.1.4	 Double Interior Vena Cavae
		2.13	 Fetal Circulation
		References
	3: Cross-Sectional Imaging Atlas
	4: Technical Aspects of Pediatric Cardiac CT
		4.1	 Introduction
		4.2	 Common Indications for Pediatric CCT
		4.3	 Technical Requirements for Pediatric Cardiac CT
		4.4	 Technical Parameters for a Successful Cardiac CT
			4.4.1	 Intravenous (IV) Access
			4.4.2	 Sedation
			4.4.3	 Fasting
			4.4.4	 Contrast Media
			4.4.5	 CT Angiography Procedure
			4.4.6	 Timing of CTA Scan
			4.4.7	 Scan Range
			4.4.8	 Single-Phase Versus Multiphase CT Angio
			4.4.9	 ECG-Gated Versus Non-ECG Gated Study
				4.4.9.1	 Non-ECG Gated Scan
				4.4.9.2	 Retrospective ECG-Gated Spiral Scan
				4.4.9.3	 Prospective ECG-Gated Sequential Scan
				4.4.9.4	 Prospectively ECG-Triggered High-Pitch Helical CT
		4.5	 Processing the Raw Data
		4.6	 Image Reconstruction
		4.7	 Keep Radiation to Minimum (ALARA)
		4.8	 Documentation and Storage of Data
		4.9	 3D Printing
		References
	5: Scan Techniques for Pediatric Cardiac MRI
		5.1	 Introduction
		5.2	 Paediatric CMR Set-Up
		5.3	 Sedation/Anaesthesia
		5.4	 Patient Positioning and Coil Placement
		5.5	 ECG Placement
		5.6	 Breath-Holding Versus Free-Breathing Scan
		5.7	 MRI Scanner
		5.8	 Contrast Media for MRI
		5.9	 MRI Acquisition Protocol
		5.10	 CMR Pulse Sequences
			5.10.1	 Black Blood Sequences
			5.10.2	 Bright Blood Cine Imaging
			5.10.3	 MR Angiography
				5.10.3.1	 Contrast MRA
					Technique
					Contrast Timing
				5.10.3.2	 Non-contrast MRA
			5.10.4	 Phase-Contrast Velocity Mapping Imaging
			5.10.5	 Myocardial Viability Imaging
		5.11	 MRI Imaging Planes
		5.12	 Standard CMR Pulse Sequences for CHD
		5.13	 Postprocessing
		5.14	 MR Imaging Safety
		References
	6: Sequential Segmental Approach to CHD
		6.1	 Introduction
		6.2	 Basic Concepts of Sequential and Segmental Approach
		6.3	 Morphologic Features of Different Cardiac Chambers
			6.3.1	 Atria
			6.3.2	 Ventricles
			6.3.3	 Great Arteries
		6.4	 Anatomical Analysis of Each Segment
		6.5	 Conclusion
		References
Part II: Imaging in Congenital Heart Disease
	7: Congenital Aortic Anomalies
		7.1	 Introduction
		7.2	 Normal Embryology
		7.3	 Imaging Protocols
			7.3.1	 CT Aortogram
			7.3.2	 MR Angiogram
		7.4	 Aortic Root Anomalies
			7.4.1	 Truncus Arteriosus
			7.4.2	 Aorto-Pulmonary Window (AP Window: APW)
			7.4.3	 Transposition of Great Arteries (TGA)
			7.4.4	 Sinus of Valsalva Aneurysm
			7.4.5	 Supravalvar Aortic Stenosis
			7.4.6	 Aorta to LV Fistula
			7.4.7	 Aortic Valve Anomalies
			7.4.8	 Ascending Aortic Atresia
		7.5	 Aortic Arch Anomalies
			7.5.1	 Hypoplastic Aortic Arch
			7.5.2	 Coarctation of Aorta
			7.5.3	 Interrupted Aortic Arch
			7.5.4	 Congenital Ductus Arteriosus Aneurysm
		7.6	 Genetic Anomalies Affecting the Aorta
			7.6.1	 Marfan Syndrome
			7.6.2	 Arterial Tortuosity Syndrome (ATS)
		References
	8: Vascular Rings and Slings
		8.1	 Introduction
		8.2	 Embryology
		8.3	 Types of Vascular Rings and Slings
			8.3.1	 Double Aortic Arch
				8.3.1.1	 Double Aortic Arch with Both Arches Patent
				8.3.1.2	 Double Aortic Arch with Atresia or Hypoplasia of One Arch with Fibrous Remnant
			8.3.2	 Left Aortic Arch with Aberrant Right Subclavian Artery and Kommerrell’s Diverticulum
			8.3.3	 Right Aortic Arch with Aberrant Left Subclavian Artery and Kommerrell’s Diverticulum
			8.3.4	 Right Circumflex Aorta and Left Circumflex Aorta
			8.3.5	 Left Aortic Arch with Aberrant Course of Right Subclavian Artery
			8.3.6	 Right Aortic Arch with Aberrant Course of Left Subclavian Artery Without Retroesophageal Diverticulum
			8.3.7	 Right Aortic Arch with Mirror-Image Branching
			8.3.8	 Innominate Artery Compression Syndrome
			8.3.9	 Pulmonary Sling
		8.4	 Conclusion
		References
	9: Radiological Review of Coronary Artery Anomalies
		9.1	 Introduction
		9.2	 Normal Anatomy of the Coronary Arteries
			9.2.1	 Coronary Artery Dominance
			9.2.2	 Right Coronary Artery (RCA)
			9.2.3	 Left Main Coronary Artery (LMCA)
			9.2.4	 Left Anterior Descending Artery (LAD)
			9.2.5	 Left Circumflex Artery (LCx)
			9.2.6	 Ramus Intermedius (RI)/(Medianus)
		9.3	 Normal Variants
			9.3.1	 Right Superior Septal Perforator
			9.3.2	 Supernumerary Coronary Ostia
			9.3.3	 Myocardial Bridging
		9.4	 Coronary Anomalies
		9.5	 Hemodynamically Significant Anomalies
			9.5.1	 Coronary Ostial Stenosis or Atresia (COSA)
			9.5.2	 Anomalous Origin of the Coronary Artery from a Ventricle
			9.5.3	 Anomalous Origin of the Coronary Artery from the Pulmonary Artery
			9.5.4	 Inter-arterial/Malignant course
			9.5.5	 Coronary Arterial Fistula
			9.5.6	 Aorto-Atrial Tunnel
		9.6	 Hemodynamically Less Significant Anomalies
			9.6.1	 Duplication
			9.6.2	 High Origin/High “Takeoff”
			9.6.3	 Single Coronary Artery (SCA)
			9.6.4	 Pre-pulmonic Course
			9.6.5	 Trans-Septal Course
			9.6.6	 Retro-Aortic Course
			9.6.7	 Acute Takeoff of LCx
			9.6.8	 Shepherd’s Crook RCA
			9.6.9	 Coronary Arcade
			9.6.10	 Extracardiac Termination
		9.7	 Conclusion
		References
	10: Imaging in Pulmonary Atresia with Ventricular Septal Defect
		10.1	 Introduction
		10.2	 Etiology
		10.3	 Embryology
		10.4	 Morphology
		10.5	 Classification
		10.6	 Pathophysiology
		10.7	 Clinical Presentation
		10.8	 Imaging Modalities
			10.8.1	 Chest X-Ray
			10.8.2	 Echocardiography
			10.8.3	 Cardiac Catheterization
			10.8.4	 MR Angiography (MRA)
				10.8.4.1	 Assessment of Morphology
				10.8.4.2	 Functional Assessment
			10.8.5	 CT Angiography (CTA)
				10.8.5.1	 Technical Factors
				10.8.5.2	 Image Post-processing
		10.9	 MDCT and MRI Evaluation of PA-VSD
			10.9.1	 Pulmonary Arteries
			10.9.2	 PDA
			10.9.3	 MAPCAs
			10.9.4	 Z-Score
			10.9.5	 McGoon’s Ratio
			10.9.6	 Nakata Index
			10.9.7	 Total Neo-pulmonary Artery Index (TNPAI)
			10.9.8	 Lung Arborization (Distribution)
			10.9.9	 Aortic Anomalies
			10.9.10	 Coronary and Intracardiac Abnormalities
			10.9.11	 Septal Defects
			10.9.12	 Intracardiac Morphology
			10.9.13	 Pulmonary and Systemic Venous System
			10.9.14	 Situs Anomalies
		10.10	 Management
			10.10.1	 Single-Stage Versus Multi-Stage Approach
				10.10.1.1	 Single-Stage Approach
				10.10.1.2	 Multi-Stage Approach
				10.10.1.3	 Comparison Between Multi- and Single-Stage Repair
		10.11	 Postoperative Assessment Using MDCT and MRI
			10.11.1	 Aortopulmonary Shunts
			10.11.2	 Classic Cavopulmonary Shunt (Glenn Operation)
			10.11.3	 The Bidirectional Glenn Shunt
			10.11.4	 Fontan Procedure
		10.12	 Limitations of MDCT
		References
	11: Congenital Pulmonary Venous Anomalies
		11.1	 Introduction
		11.2	 Embryology of the Pulmonary Veins
		11.3	 Normal Pulmonary Venous Anatomy
		11.4	 Normal Variant Pulmonary Venous Drainage
		11.5	 Imaging Modalities
			11.5.1	 Chest Radiography
			11.5.2	 Echocardiography
			11.5.3	 CT Scan
			11.5.4	 MRI
		11.6	 Congenital Pulmonary Vein Anomalies
			11.6.1	 Total Anomalous Pulmonary Venous Drainage (TAPVD)
				11.6.1.1	 Imaging of TAPVD: Chest Radiography
			11.6.2	 Partial Anomalous Pulmonary Venous Drainage (PAPVD)
				11.6.2.1	 Imaging of PAPVD: Chest Radiography
				11.6.2.2	 CT/MRA
			11.6.3	 Sinus Venosus Defect
			11.6.4	 Congenital Pulmonary Venolobar Syndrome
				11.6.4.1	 Scimitar Syndrome
				11.6.4.2	 Pulmonary Sequestrations and Variants
				11.6.4.3	 Horseshoe Lung
		11.7	 Malposition of the Septum Primum
		11.8	 Meandering Pulmonary Vein
		11.9	 Levoatriocardinal Vein
		11.10	 Cor Triatriatum
		11.11	 Pulmonary Vein Stenosis/Hypoplasia/Atresia
		11.12	 Pulmonary Vein Varix
		11.13	 Pulmonary Arteriovenous Malformation
		11.14	 Post-operative TAPVD
		11.15	 Summary
		References
	12: CT and MRI of Simple Cardiovascular Shunts
		12.1	 Introduction
		12.2	 Atrial Septal Defect (ASD)
			12.2.1 Introduction
			12.2.2 Normal Anatomy of Inter-Atrial Septum (Fig. 12.2)
			12.2.3 Classification of ASD (Fig. 12.3)
			12.2.4 Ostium Secundum ASD (Fig. 12.4)
			12.2.5 Ostium Primum ASD (Fig. 12.5)
			12.2.6 Sinus Venosus ASD (Figs. 12.6 and 12.7)
			12.2.7 Unroofed Coronary Sinus (Fig. 12.8)
			12.2.8 Common Atrium
			12.2.9 Patent Foramen Ovale (PFO) (Figs. 12.9 and 12.10)
			12.2.10 Clinical Features
			12.2.11 Imaging Findings
			12.2.12 Treatment
		12.3	 Ventricular Septal Defect (VSD)
			12.3.1 Introduction
			12.3.2 Embryology (Figs. 12.11 and 12.12)
			12.3.3 Normal Anatomy of Interventricular Septum (Figs. 12.13, 12.14, and 12.15)
			12.3.4 Pathophysiology of VSD
			12.3.5 Complications of VSD
			12.3.6 Classification
			12.3.7 Imaging Findings
				12.3.7.1	 Central Perimembranous VSD (Figs. 12.16 and 12.17)
				12.3.7.2	 Muscular: Trabecular VSD (Figs. 12.18 and 12.19)
				12.3.7.3	 Inlet VSD (Fig. 12.20)
				12.3.7.4	 Outlet VSD (Fig. 12.21)
			12.3.8 Clinical Presentation
			12.3.9 Treatment
		12.4	 Atrio-Ventricular Septal Defect (AVSD)
			12.4.1 Introduction
			12.4.2 Classification [15] (Table 12.3)
			12.4.3 Associations
			12.4.4 Pathophysiology
			12.4.5 Clinical Presentation
			12.4.6 Imaging Findings (Fig. 12.22)
			12.4.7 Treatment
		12.5	 Patent Ductus Arteriosus (PDA)
			12.5.1 Introduction
			12.5.2 Embryology
			12.5.3 Morphology
			12.5.4 Pathophysiology
			12.5.5 Clinical Features
			12.5.6 Imaging Findings
			12.5.7 Treatment
		12.6	 MRI Quantification of Shunts [26, 27]
			12.6.1 Calculating Shunt Across Atrial Septal Defect (Fig. 12.30)
			12.6.2 Calculating Shunt Across Ventricular Septal Defect (Fig. 12.31)
			12.6.3 Calculating Shunt Across Patent Ductus Arteriosus (Fig. 12.32)
			12.6.4 Illustrative Examples
		References
	13: Ebstein Anomaly
		13.1	 Introduction
		13.2	 Epidemiology and Risk Factors
		13.3	 Embryology
		13.4	 Pathological Anatomy
		13.5	 Associated Abnormalities
		13.6	 Pathophysiology
		13.7	 Classifications
		13.8	 Clinical Presentation
		13.9	 Approach to Diagnosis and Evaluation
		13.10	 Imaging Tests
			13.10.1	 Chest Radiograph (CXR)
			13.10.2	 Echocardiography
				13.10.2.1	 Transesophageal Echocardiogram (TEE)
			13.10.3	 CT
				13.10.3.1	 Indications for CT
			13.10.4	 CMR
			13.10.5	 CMR Protocol
			13.10.6	 Preoperative CMR Imaging Checklist
			13.10.7	 Postoperative CMR Imaging Checklist
		13.11	 Treatment
			13.11.1	 Prenatal
			13.11.2	 Neonates
			13.11.3	 Children, Adolescents, and Adults
		13.12	 Ebsteinoid Malformation of Left AV Valve in L-TGA
		13.13	 Differential Diagnosis
		References
	14: Pre- and Postoperative Imaging in Tetralogy of Fallot
		14.1	 Definition
		14.2	 Introduction
		14.3	 Pathophysiology
		14.4	 Management of TOF
			14.4.1 Single-Stage Repair
			14.4.2 Multi-stage Repair
			14.4.3 Natural History Post Surgery
		14.5	 Imaging Techniques
			14.5.1 Chest Radiograph
			14.5.2 Echocardiography
			14.5.3 Cardiac Catheterization
			14.5.4 Computed Tomography Angiography (CTA)
			14.5.5 Cardiac MR (CMR)
		14.6	 Preoperative Imaging of TOF
			14.6.1 Characterization of Primary Lesion
				14.6.1.1	 Right Ventricle Outflow Tract Obstruction (RVOTO)
				14.6.1.2	 Ventricular Septal Defect
			14.6.2 Pulmonary Arteries
				14.6.2.1	 Aortic Anatomy
				14.6.2.2	 Coronary Anatomy
				14.6.2.3	 Atrial Septal Defects
				14.6.2.4	 Pulmonary Venous Return
				14.6.2.5	 Airway Compression
		14.7	 Postoperative Imaging in TOF
			14.7.1 Imaging Post BT Shunt
			14.7.2 Imaging Post Intracardiac Repair (ICR)
		14.8	 Conclusion
		References
	15: Double Outlet Right Ventricle: Morphology and Function
		15.1	 Introduction
		15.2	 History
		15.3	 Embryology
		15.4	 Pathophysiology
		15.5	 CT and MR Imaging Techniques
			15.5.1	 MSCT
			15.5.2	 MRI Techniques
		15.6	 Morphology of DORV
		15.7	 Common Variants of DORV (Summarized in Table 15.1)
			15.7.1	 Tetralogy of Fallot (TOF)-Like Variant (Figs. 15.5, 15.6, and 15.7)
			15.7.2	 Transposition of Great Arteries (TGA)-Like Variant (Taussig–Bing Anomaly) (Figs. 15.8, 15.9, 15.10, 15.11, and 15.12)
			15.7.3	 Variant Resembling VSD (Fig. 15.13)
			15.7.4	 Variant Resembling a Univentricular Heart (Figs. 15.14, 15.15, and 15.16)
		15.8	 Less Frequent Variants of DORV
			15.8.1	 DORV with Subaortic VSD, Aorta Left to Pulmonary Trunk with PS (Figs. 15.17 and 15.18)
			15.8.2	 DORV with Noncommitted VSD (Fig. 15.19)
			15.8.3	 DORV with Discordant Atrioventricular Connection (Figs. 15.20 and 15.21)
			15.8.4	 DORV with Mirror-Image Atrial Arrangement (Fig. 15.22)
			15.8.5	 DORV with Isomeric Atrial Appendages (Ambiguous AV Connection)
			15.8.6	 DORV Without VSD
		15.9	 Associated Other Cardiac Anomalies
			15.9.1	 Juxtaposition of the Atrial Appendages (Fig. 15.28)
			15.9.2	 Abnormalities of the Atrioventricular Valves
		15.10	 3D Printing in DORV
		15.11	 Surgical Repair [29–33]
			15.11.1	 LV to Aorta Routability
			15.11.2	 Postoperative Complications
		15.12	 Double Outlet Left Ventricle (DOLV)
		15.13	 Conclusion
		References
	16: Pre- and Postoperative Imaging in Transposition of Great Arteries
		16.1	 Introduction
		16.2	 Embryology
		16.3	 Morphology
			16.3.1	 Coronary Arteries in TGA [5, 6]
		16.4	 Differential Diagnosis
		16.5	 Pathophysiology
		16.6	 Clinical Aspects
		16.7	 Management of TGA
			16.7.1	 Surgical Options
		16.8	 Expected Complications of Surgery
		16.9	 Imaging in TGA
		16.10	 Postoperative evaluation [15]
			16.10.1	 Senning and Mustard Repair
			16.10.2	 Arterial Switch Operation
			16.10.3	 Rastelli Operation
			16.10.4	 Double Switch Surgery
			16.10.5	 Nikaidoh Procedure
		16.11	 Comparison Between Cardiac CT Versus Cardiac MRI
		References
	17: Imaging of Single Ventricle
		17.1	 Introduction
		17.2	 Evolution of Concept of Single Ventricle
		17.3	 Classification
			17.3.1	 True Univentricular Heart
			17.3.2	 Functionally Univentricular Heart
		17.4	 Physiology of Univentricular Hearts
		17.5	 Pattern/Arrangement of Univentricular Heart
			17.5.1	 Univentricular Hearts That Are Morphological LV
			17.5.2	 Univentricular Heart with Morphological Right Ventricle
		17.6	 Epidemiology and Natural History
		17.7	 Fontan Circulation
		17.8	 Imaging of the Single Ventricle
			17.8.1	 ECG
			17.8.2	 X-Ray
			17.8.3	 Echocardigraphy (Figs. 17.9, 17.10, 17.11, and 17.12)
				17.8.3.1	 Approach
				17.8.3.2	 AV Valve
				17.8.3.3	 Great Arteries
			17.8.4	 Cardiac MRI (Figs. 17.13, 17.14, 17.15, and 17.16)
			17.8.5	 Cardiac CT (Figs. 17.16, 17.17, 17.18, 17.19, and 17.20)
				17.8.5.1	 Scanning Protocol
				17.8.5.2	 Image Analysis
			17.8.6	 Cardiac Catheterisation
		17.9	 Common Conditions Producing Univentricular Heart
			17.9.1	 Tricuspid Atresia
			17.9.2	 Double Inlet Left Ventricle (DILV)
			17.9.3	 Hypoplastic Left Heart Syndrome
		17.10	 Conclusion
		References
	18: CT and MR Imaging in Post-operative CHD
		18.1	 Introduction
		18.2	 Suggested Imaging Protocol
			18.2.1	 CMR Protocol
			18.2.2	 CTA Protocol
		18.3	 Common Surgical Procedures Used for Palliation and Correction of CHDs and Their Imaging Findings
		18.4	 Palliative Procedures
			18.4.1	 Other Palliative Procedures
		18.5	 Corrective Surgeries for Common CHDs
			18.5.1	 Tetralogy of Fallot (TOF)
			18.5.2	 Transposition of Great Arteries (TGA)
			18.5.3	 Double Outlet Right Ventricle (DORV)
			18.5.4	 Coarctation of Aorta
		18.6	 Imaging of Complications of Palliative Shunts
		18.7	 Imaging of Complications of Repaired CHDs
			18.7.1	 Tetralogy of Fallot (TOF) and TOF-Type Double Outlet Right Ventricle (DORV)
			18.7.2	 Transposition of Great Arteries (TGA) and TGA-Type Double Outlet Right Ventricle (DORV)
			18.7.3	 Coarctation of Aorta
		18.8	 Conclusion
		References
	19: Valvular Heart Disease
		19.1	 Introduction
			19.1.1	 MRI Assessment of Valve Morphology
			19.1.2	 Flow Mechanics and Valve Mathematics
				19.1.2.1	 Normal Flow Patterns
				19.1.2.2	 Abnormal Flow Patterns
			19.1.3	 MRI Techniques to Evaluate Valvular Function
				19.1.3.1	 Qualitative Assessment of Valve Function
				19.1.3.2	 Quantitative Assessment of Valve Function
					Potential Pitfalls of Flow Quantification Using Phase-Contrast Imaging
					Interpretation of Phase-Contrast Flow Maps
		19.2	 Merits and Limitations of Echocardiography and CMR
		19.3	 Role of CT in the Assessment of VHD
		19.4	 Aortic Valve
			19.4.1	 Aortic Stenosis
				19.4.1.1	 Ventricular Mass, Function, and Tissue Characterization
				19.4.1.2	 Aortic Root Evaluation
			19.4.2	 Aortic Regurgitation
		19.5	 Mitral Valve
			19.5.1	 Mitral Stenosis
			19.5.2	 Mitral Regurgitation
		19.6	 Pulmonary Valve
			19.6.1	 Pulmonary Stenosis
			19.6.2	 Pulmonary Regurgitation
		19.7	 Tricuspid Valve
			19.7.1	 Tricuspid Stenosis
			19.7.2	 Tricuspid Regurgitation
		19.8	 Prosthetic Valves
		19.9	 Conclusion
		References
Part III: Special Topics in CHD
	20: Techniques and Clinical Applications of Phase-Contrast MRI in CHD
		20.1	 Introduction
		20.2	 Phase-Contrast MRI: Basic Concepts
		20.3	 Imaging Technique
			20.3.1	 Basic Scan Parameters
			20.3.2	 Recommended Velocities
		20.4	 Planning for Specific Vessels
			20.4.1	 Ascending Aorta
			20.4.2	 Main Pulmonary Artery
			20.4.3	 Branch Pulmonary Arteries
			20.4.4	 Superior Vena Cava
			20.4.5	 Descending Aorta
			20.4.6	 Pulmonary Veins
			20.4.7	 Atrio Ventricular Valve
		20.5	 Image Post-processing
			20.5.1	 Practical Pearls for PC Flow study Post Processing
			20.5.2	 Internal Checking
		20.6	 Comparison with Doppler USG
		20.7	 Pitfalls of PC-MRI and the Remedies
			20.7.1	 Improper Selection of VENC
			20.7.2	 Improper Vessel Alignment
			20.7.3	 Inadequate Temporal Resolution
			20.7.4	 Inadequate Spatial Resolution
			20.7.5	 Magnetic Field Inhomogeneity
			20.7.6	 Flow-Related Signal Loss
			20.7.7	 Pulsation Artifacts
			20.7.8	 Phase Offset Error
			20.7.9	 Prospective Gating
		20.8	 Clinical Applications of PC-MRI
			20.8.1	 Presence of Flow
			20.8.2	 To Know the Direction of Blood Flow
			20.8.3	 Gradient Across the Stenosis
			20.8.4	 Calculation of Valve Regurgitation
				20.8.4.1	 Methods to Calculate Isolated Pulmonary Regurgitant Volume
				20.8.4.2	 Methods to Calculate Isolated Tricuspid Regurgitant Volume
			20.8.5	 Calculation of Shunts
			20.8.6	 Evaluation of Collateral Flow Circulation
			20.8.7	 Assessment of Differential Lung Perfusion
			20.8.8	 Velocity Waveforms and Flow Patterns
				20.8.8.1	 Diastolic Function Assessment by Transmitral Flow
				20.8.8.2	 Pulmonary Venous PC
				20.8.8.3	 Assessment of Pulmonary Hypertension
			20.8.9	 Practical Pearls
		20.9	 Newer Applications
			20.9.1	 “Real-Time” Flow Imaging
			20.9.2	 Coronary Artery Blood Flow (CBF)
			20.9.3	 3D and 4D Flow
		20.10	 Conclusions
		References
	21: Imaging of Pulmonary Hypertension in Congenital Heart Disease
		21.1	 What Is Pulmonary Hypertension?
		21.2	 Classification of PH
		21.3	 Pathophysiology of PH
		21.4	 Pathophysiology of PAH in CHD
		21.5	 Prevalence of PAH in CHD
		21.6	 Cross-Sectional Imaging
			21.6.1	 CT Protocols
			21.6.2	 MRI Protocols
		21.7	 Diagnosis and Detection of PAH
			21.7.1	 CT Assessment
			21.7.2	 MRI Assessment
		21.8	 Functional Assessment
			21.8.1	 Cine Imaging
			21.8.2	 Phase-Contrast Imaging
			21.8.3	 Other Functional Parameters
		21.9	 Role of CT/MRI in PAH Associated with CHD
		21.10	 Newer Advances in MRI
		21.11	 Practical Tips
		21.12	 Summary
		References
	22: CT Versus MRI in Congenital Heart Disease
		22.1	 Introduction
		22.2	 CT Imaging in CHD
			22.2.1	 Technical and Equipment Requirements for Cardiac CT
				22.2.1.1	 Spatial Resolution
				22.2.1.2	 Temporal Resolution
				22.2.1.3	 Pitch
				22.2.1.4	 High-Pitch CT Scan
				22.2.1.5	 ECG Gated Versus Non-gated Study
			22.2.2	 Protocoling a CT CHD Study
		22.3	 MR in Congenital Heart Disease
			22.3.1	 Morphological Imaging
			22.3.2	 Cine Imaging
			22.3.3	 Phase-Contrast Imaging (PC)
			22.3.4	 Delayed Enhancement Imaging
			22.3.5	 Contrast-Enhanced Magnetic Resonance Angiography (CE-MRA)
				22.3.5.1 3D CE-MRA
		22.4	 Protocols for Common Conditions (Table 22.1)
		22.5	 CT Versus CMR for Congenital Heart Disease
		22.6	 3D Printing
		22.7	 Imaging in Cardiac Shunts
			22.7.1	 MRI
			22.7.2	 Atrial Septal Defects
				22.7.2.1 Types of ASD
				22.7.2.2	 Ostium Primum ASD
				22.7.2.3	 Ostium Secundum ASD
				22.7.2.4	 Sinus Venosus ASD
				22.7.2.5	 Coronary Sinus (CS) Defect
				22.7.2.6	 CT and MRI: When and Why
				22.7.2.7	 Practical Pearl
				22.7.2.8	 Atrioventricular Cushion/Septal Defects (AVCD/AVSD)
				22.7.2.9	 Types of AVSD
				22.7.2.10	 CT and MRI: When and Why
				22.7.2.11	 Practical Pearls
			22.7.3	 Ventricular Septal Defects
				22.7.3.1	 Type 1
				22.7.3.2	 Type 2
				22.7.3.3	 Type 3
				22.7.3.4	 Type 4
				22.7.3.5	 CT and MR: When and Why
				22.7.3.6	 Practical Pearl
		22.8	 Venoatrial Anomalies
			22.8.1	 Partial Anomalous Pulmonary Venous Connection
			22.8.2	 Total Anomalous Pulmonary Venous Return (TAPVC)
			22.8.3	 CT and MR Imaging: Where and Why
				22.8.3.1	 Practical Pearls
		22.9	 Tetralogy of Fallot (TOF)
			22.9.1	 Anatomy
			22.9.2	 Associated Anomalies
			22.9.3	 CT and MRI: When and Why
			22.9.4	 CMR in TOF
			22.9.5	 Practical Pearls
		22.10	 Double-Outlet Ventricles: DORV
			22.10.1	 CT and MRI: When and Why
		22.11	 Transposition of Great Arteries (TGA)
			22.11.1 D-TGA (Ventriculoarterial Discordance, Atrioventricular Concordance)
			22.11.2	 L-TGA or ccTGA (Atrioventricular and Ventriculoarterial Discordance: Double Discordance)
			22.11.3	 Surgical Modalities in TGA
			22.11.4	 CT and MRI: When and Why
		22.12	 Post-surgical TGA
			22.12.1	 Ebstein’s Anomaly
			22.12.2	 CT and MRI: When and Why
			22.12.3	 Carpentier Classification [75]
			22.12.4	 Practical Pearls
		22.13	 Coarctation of Aorta (CoA)
			22.13.1	 CT and MRI: When and Why
			22.13.2	 Imaging in Repaired Coarctation of Aorta
		22.14	 Conclusion
		References
	23: Echocardiography for Congenital Heart Disease: Fundamental Approach
		23.1	 Introduction
		23.2	 History of Echocardiography
		23.3	 Advantages of Echocardiography
		23.4	 Objectives of Echocardiography
		23.5	 General Guidelines for Echocardiography
		23.6	 Optimal Image Acquisition
			23.6.1	 Choice of Transducer and Frequency
			23.6.2	 Standardization and Optimization
			23.6.3	 Imaging Protocols
			23.6.4	 The Segmental Approach
		23.7	 Views and Scanning Techniques
		23.8	 Specific Views
			23.8.1	 Subxiphoid Views
			23.8.2	 Subxiphoid Long-Axis Sweep
			23.8.3	 Subxiphoid Short-Axis Sweep
			23.8.4	 Apical Views
			23.8.5	 Parasternal Views
			23.8.6	 High-Parasternal (“Ductal”) View
			23.8.7	 Suprasternal Views
		23.9	 Hemodynamic Assessment
		23.10	 Summary
		References
	24: 3D Prototyping: Technology and Applications for CHD
		24.1	 Introduction
		24.2	 What Is 3D Printing or Additive Manufacturing?
		24.3	 Different Types of 3D Printing Technologies and How They Work
		24.4	 Brief History of Additive Manufacturing
		24.5	 3D Printing in Medicine and in Cardiovascular Sciences
		24.6	 Steps in Cardiovascular 3D Printing
			24.6.1	 Step 1: Imaging
			24.6.2	 Step 2: Segmentation, Design, and Creation of the Digital 3D Object
			24.6.3	 Step 3: Consideration of the Printing Technology and Material to Be Used
			24.6.4	 Step 4: Export of Digital 3D File to 3D Printer Software and Hardware
			24.6.5	 Step 5: Printing and Post-processing
		24.7	 Caveats of 3D Models
		24.8	 Illustrative Case Examples
		24.9	 Summary
		References
	25: Radiation Issues in Pediatric Cardiac CT Imaging
		25.1	 Introduction
		25.2	 Basic Radiation Dosimetry Parameters
			25.2.1	 Absorbed Dose
			25.2.2	 Equivalent Dose
			25.2.3	 Effective Dose
		25.3	 Radiation Risks from Performing Cardiac CT in Pediatric Age Group
		25.4	 Steps for Lowering the Radiation Dose from CT to Pediatric Population
			25.4.1	 Appropriate Selection of Patient
			25.4.2	 Patient Centering in the Gantry
			25.4.3	 Contrast Delivery
			25.4.4	 Appropriate Coverage
			25.4.5	 mAs and kVp Settings
			25.4.6	 Pitch of Scan
			25.4.7	 Thicker Detector Width
			25.4.8	 Iterative Reconstruction
			25.4.9	 Prospective/Retrospective ECG Gating and Non-ECG Pulsing
		References