Magnetic Resonance Imaging of Congenital Heart Disease

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Comparison of MRI and transthoracic 3-dimensional echocardiography. Rofo ; — Normal human left and right ventricular and left atrial dimensions using steady state free precession magnetic resonance imaging.

  • Magnetic resonance imaging of congenital heart disease in adults.
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J Cardiovasc Magn Reson ; — Boxt LM. Cardiac MR imaging: a guide for beginners. Radiographics ; — Advanced Search Users Online: Role of cardiac MRI in diagnosis of congenital heart diseases. Benha Med J ; Table 1 Suggested imaging protocols for given conditions for abbreviations see main text [7] Click here to view. Table 2 Classification of patients according to their age and sex Click here to view. Table 3 Classification of the patients according to the pathologic diagnosis Click here to view.

Table 4 Number of other imaging modalities done Click here to view. Figure 1 Trufi steady-state free precession sequence axial and showing membranous ventricular septal defect in 8-year-old male. Click here to view. Figure 2 Tetralogy of Fallot. Cardiac MRI with steady-state free precession showing a oblique projection with the aorta overriding a malalignment ventricular septal defect asterisk , b sagittal projection with severe infundibular and pulmonary valve stenosis, and c three-dimensional mri angiography MRA , axial view, with severe hypoplasia of the main and right pulmonary artery, and the presence of right aortic arch [8].

Figure 3 Classification of the patients according to the pathologic diagnosis. VSD, ventricular septal defect. Related articles cardiac MRI congenital heart diseases cardiac imaging. Access Statistics. Sitemap What's New Feedback Disclaimer. Reduced global longitudinal and radial strain with normal left ventricular ejection fraction late after effective repair of aortic coarctation: a CMR feature tracking study.

Slice location dependence of aortic regurgitation measurements with MR phase velocity mapping. Quantitation of antegrade and retrograde blood flow in the human aorta by magnetic resonance velocity mapping. Assessment of left-to-right intracardiac shunting by velocity-encoded, phase-difference magnetic resonance imaging. A comparison with oximetric and indicator dilution techniques.

Noninvasive quantification of left-to-right shunt in pediatric patients: phase-contrast cine magnetic resonance imaging compared with invasive oximetry. Comprehensive 4D velocity mapping of the heart and great vessels by cardiovascular magnetic resonance. Reproducibility of MRI measurements of right ventricular size and function in patients with normal and dilated ventricles. The role of transcytolemmal water exchange in magnetic resonance measurements of diffuse myocardial fibrosis in hypertensive heart disease. Quantification of diffuse myocardial fibrosis and its association with myocardial dysfunction in congenital heart disease.

Haemodynamic findings on cardiac CT in children with congenital heart disease. Multidetector computed tomography in the adolescent and young adult with congenital heart disease. Adult congenital heart disease imaging with second-generation dual-source computed tomography: initial experiences and findings. Crown years for non-invasive cardiovascular imaging Part IV : 30 years of cardiac computed tomography. Cardiothoracic ratio from postero-anterior chest radiographs: a simple, reproducible and independent marker of disease severity and outcome in adults with congenital heart disease.

Long-term outcome in patients undergoing surgical repair of tetralogy of Fallot. Left ventricular dysfunction is a risk factor for sudden cardiac death in adults late after repair of tetralogy of Fallot. Factors associated with impaired clinical status in long-term survivors of tetralogy of Fallot repair evaluated by magnetic resonance imaging. Right ventricular function in adults with repaired tetralogy of Fallot assessed with cardiovascular magnetic resonance imaging: detrimental role of right ventricular outflow aneurysms or akinesia and adverse right-to-left ventricular interaction. Reliability and accuracy of echocardiographic right heart evaluation in the U.

Melody Valve Investigational Trial. Echocardiography for assessment of right ventricular volumes revisited: a cardiac magnetic resonance comparison study in adults with repaired tetralogy of Fallot. Optimal timing for pulmonary valve replacement in adults after tetralogy of Fallot repair. Remodelling of the right ventricle after early pulmonary valve replacement in children with repaired tetralogy of Fallot: assessment by cardiovascular magnetic resonance.

Characterization of right ventricular diastolic performance after complete repair of tetralogy of Fallot. Restrictive physiology predicts slow postoperative recovery. Diastolic function in repaired tetralogy of Fallot at rest and during stress: assessment with MR imaging. Impact of restrictive physiology on intrinsic diastolic right ventricular function and lusitropy in children and adolescents after repair of tetralogy of Fallot.

Frontiers | 3D Whole Heart Imaging for Congenital Heart Disease | Pediatrics

Right ventricular-left ventricular interaction in adults with Tetralogy of Fallot: A combined cardiac magnetic resonance and echocardiographic speckle tracking study. Right ventricular peak systolic longitudinal strain is a sensitive marker for right ventricular deterioration in adult patients with tetralogy of Fallot. Impaired right and left ventricular diastolic myocardial mechanics and filling in asymptomatic children and adolescents after repair of tetralogy of Fallot. Quantifying pulmonary regurgitation and right ventricular function in surgically repaired tetralogy of Fallot: a comparative analysis of echocardiography and magnetic resonance imaging.

Optimal imaging in assessment of right ventricular function in tetralogy of Fallot with pulmonary regurgitation. Pulmonary regurgitation in the late postoperative follow-up of tetralogy of Fallot. Volumetric quantitation by nuclear magnetic resonance velocity mapping. Repaired tetralogy of Fallot: the roles of cardiovascular magnetic resonance in evaluating pathophysiology and for pulmonary valve replacement decision support. Cardiovascular magnetic resonance in the follow-up of patients with corrected tetralogy of Fallot: a review.

Assessment of the accuracy and reproducibility of RV volume measurements by CMR in congenital heart disease. Refining the assessment of pulmonary regurgitation in adults after tetralogy of Fallot repair: should we be measuring regurgitant fraction or regurgitant volume? Evaluation by MRA of aortic dilation late after repair of tetralogy of Fallot. International journal of cardiology. Ventricular fibrosis suggested by cardiovascular magnetic resonance in adults with repaired tetralogy of Fallot and its relationship to adverse markers of clinical outcome.

Long-term outcomes after the atrial switch for surgical correction of transposition: a meta-analysis comparing the Mustard and Senning procedures. The right ventricular response to high afterload: comparison between healthy persons and patients with transposition of the great arteries: a 2D strain study. The role of echocardiography in the assessment of right ventricular systolic function in patients with transposition of the great arteries and atrial redirection. Magnetic resonance imaging evaluation of congenital heart disease: conotruncal anomalies.

Late outcome after arterial switch operation for transposition of the great arteries. Long-term predictors of aortic root dilation and aortic regurgitation after arterial switch operation. Complete repair of transposition of the great arteries with pulmonary stenosis. A review and report of a case corrected by using a new surgical technique. Coarctation Long-term Assessment COALA : significance of arterial hypertension in a cohort of patients up to 27 years after surgical repair of isolated coarctation of the aorta, even in the absence of restenosis and prosthetic material.

Doppler echocardiographic profile and indexes in the evaluation of aortic coarctation in patients before and after stenting. Continuous wave Doppler echocardiography and coarctation of the aorta: gradients and flow patterns in the assessment of severity. Incidence of aneurysm formation after Dacron patch aortoplasty repair for coarctation of the aorta: long-term results and assessment utilizing magnetic resonance angiography with three-dimensional surface rendering.

Contrast-enhanced MR angiography of cavopulmonary connections in adult patients with congenital heart disease. Myocardial fibrosis identified by cardiac magnetic resonance late gadolinium enhancement is associated with adverse ventricular mechanics and ventricular tachycardia late after Fontan operation. Imaging atrial septal defects by real-time three-dimensional transesophageal echocardiography: step-by-step approach.

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  4. Effect of atrial septal defect shape evaluated using three-dimensional transesophageal echocardiography on size measurements for percutaneous closure. Progressive tricuspid valve disease in patients with congenitally corrected transposition of the great arteries. Congenitally corrected transposition of the great arteries ventricular function at the time of systemic atrioventricular valve replacement predicts long-term ventricular function. Evaluating the systemic right ventricle by CMR: the importance of consistent and reproducible delineation of the cavity.

    Congenitally corrected transposition of the great arteries: MDCT angiography findings and interpretation of complex coronary anatomy. Early insertion of a pulmonary valve for chronic regurgitation helps restoration of ventricular dimensions. Preoperative thresholds for pulmonary valve replacement in patients with corrected tetralogy of Fallot using cardiovascular magnetic resonance.

    Magnetic resonance imaging evaluation of congenital heart disease: conotruncal anomalies.

    Biventricular response after pulmonary valve replacement for right ventricular outflow tract dysfunction: is age a predictor of outcome? Randomized trial of pulmonary valve replacement with and without right ventricular remodeling surgery. Outcomes of pulmonary valve replacement in patients with chronic pulmonary regurgitation after relief of right ventricular outflow tract obstruction: implications for optimal timing of pulmonary valve replacement. Published on behalf of the European Society of Cardiology. All rights reserved. For permissions please email: journals. Issue Section:. Download all figures.

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    Please check for further notifications by email. View Metrics. Email alerts New issue alert. Advance article alerts. Article activity alert. Receive exclusive offers and updates from Oxford Academic. More on this topic The ABCs of left ventricular assist device echocardiography: a systematic approach. European Association of Echocardiography recommendations for the assessment of valvular regurgitation.

    Part 1: aortic and pulmonary regurgitation native valve disease. Two-dimensional strain to assess regional left and right ventricular longitudinal function in normal foetuses. P The importance of contractile reserve when assessing asymptomatic patients with aortic stenosis. Related articles in Web of Science Google Scholar. Citing articles via Web of Science Latest Most Read Most Cited Right-sided infective endocarditis with coronary sinus vegetation causing complete atrioventricular block.

    Accuracy of fully automated right ventricular quantification software with 3D echocardiography: direct comparison with cardiac magnetic resonance and semi-automated quantification software. Old wine in a new bottle: non-invasive quantitative evaluation of pulmonary congestion with pulmonary blood volume index by cardiac magnetic resonance. European Association of Cardiovascular Imaging expert consensus paper: a comprehensive review of cardiovascular magnetic resonance normal values of cardiac chamber size and aortic root in adults and recommendations for grading severity.

    First-line non-invasive imaging technique; high temporal resolution; real-time imaging capability; superior for intra-cardiac structures, hemodynamic assessment, and velocity measurement. Superior in assessing valve disease and septal defects, estimating gradients, PA pressure, and detecting highly mobile structures such as vegetation. Superior for imaging posterior cardiac structures, monitoring during interventional and surgical procedures; high sensitivity for the detection of thrombi and vegetations.

    May be helpful in guiding percutaneous interventional procedures, no need for sedation or oesophageal intubation. Evaluation of pulmonary arteries and the aorta; evaluation of systemic and pulmonary veins anomalous connection, obstruction, etc. Measurements of flow volumes, quantification of pulmonary and aortic regurgitation, quantification of shunts. Visualization of multidirectional blood flow in a 3-D volume, pathline visualization may be helpful in selected ACHD patients. Excellent spatial resolution; fast acquisition time; alternative to CMR in patients with pacemaker or implantable cardioverter defibrillator.

    Often, the type of AV connection, possible presence of ventricular septal defect VSD and the type of arterioventricular connection can be accurately determined by TTE with apical view. The arrangement of the great arteries is easier to determine with transversal planes along the parasternal or subcostal view. In a few adult patients with complex congenital heart disease, it may be impossible to define the direction of blood flow. Multiplanar TEE provides very precise information in such patients on the type and mode of AV and ventri-cular-arterial connection, and on the morphology of each ventricle 7 Figure Transesophageal echocardiogram of a patient with situs inversus and atrioventricular discordance.

    A and B four-chamber plane in systole and diastole : the atrial septum arrows forms nearly a right angle with the ventricular septum; the right ventricle RV , located to the right, is recognized by the morphology of the tricuspid valve T , and the left ventricle LV , located to the left, by the morphology of the mitral valve M. C transverse plane : the left atrium LA , located to the right, is recognized by the morphology of the appendage LApp.

    D: after injection of contrast, the right atrium RA and the left ventricle are filled, but there is no flow of contrast to the chambers of the right side.. The most frequent venous drainage anomalies in adults affect the venae cavae and do not have any functional repercussions, but an incidental anomaly may confuse the interpretation of the heart images, whatever the technique used, or alter the surgical approach or invasive procedures. The most common anomalies are persistent left superior vena cava drainage to the coronary sinus and stenosis of the inferior vena cava with continuation via the azygos or homozygous system.

    Transthoracic echocardiography can detect these anomalies. The suprasternal view will show the presence of a superior left vena cava and determine whether the innominate vein connects the two superior venae cavae. We can inject sonicated serum into a peripheral vein to help delineate the drainage chamber of the different venous territories.

    However, echocardiography does not allow the entire anomalous venous course to be determined, and angiocardiography and MRI are needed for accurate diagnosis. Currently, MRI is the technique of choice for defining venous drainage anomalies in adult patients 8 because it can accurately delineate incidental anomalies, as well as the rare cases of non-incidental vena cava anomalies, such as drainage of the inferior vena cava or the left or right superior vena cava into the left atrium.. Magnetic resonance imaging is even more useful in the evaluation of pulmonary venous drainage.

    The most frequent anomaly in adults is partial anomalous drainage of pulmonary veins. Anomalous drainage occurs more frequently in the superior pulmonary vein, but it can also affect the left pulmonary veins or infe-rior pulmonary veins, particularly the right inferior pulmonary vein. An anomalous right superior pulmonary vein will normally drain into the superior vena cava or the junction between the superior vena cava and the right atrium, and it is associated with sinovenous atrial septal defect ASD. Anomalous drainage of a superior left pulmonary vein normally occurs via a left vertical vein that runs into the innominate vein.

    Anomalous drainage of an inferior pulmonary vein normally the right one is usually to the inferior vena cava, giving rise to scimitar syndrome Figure 4. Although these anomalous shunts may be much better assessed by TEE, the current technique of choice for diagnosis of these anomalies is MRI. Magnetic resonance imaging in a patient with scimitar syndrome. Stenosis of the IVC arrow occurred after surgical correction. The stenosis was resolved by angioplasty.. Interatrial shunts normally result from ASD within the confines of the fossa ovalis ostium secundum. The ASD may also rarely be located in the coronary sinus unroofed coronary sinus or affect the entire atrial septum single atrium.

    The diagnostic sensitivity is very high for any type of ASD, though a sinovenous ASD sometimes causes difficulties for transthoracic examination, particularly if the subcostal view is inadequate. Transesophageal echocardiography is better than conventional echocardiography for determining the size, number, morphology and location of defects.

    In all patients suspected to have or with confirmation of sinovenous ASD, as the shunt is normally associated with vena cava drainage anomalies overriding and anomalous pulmonary veins that cannot be analyzed satisfactorily by TTE 11 Figure Transesophageal echocardiogram in a patient with sinovenous atrial septal defect. A transversal plane : the defect arrow is located between the superior vena cava SVC and the left atrium LA.

    B longitudinal plane : the SVC straddles both atria.

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    RA indicates right atrium.. Whenever the therapeutic approach requires accurate determination of the size, number, morphology or exact position of the defects. To determine the borders of the defect whenever percutaneous closure of the ASD is considered, and to predict the possibility of success with this technique 12 Figure A, B and C: transesophageal echocardiogram during placement of Amplatzer device arrow for percutaneous closure of an ostium secundum atrial septal defect. RA indicates right atrium; LA, left atrium..

    The remaining patients can be managed using the findings from TTE, though we normally complete the information from this technique by performing radionuclide ventriculography to quantify the left-to-right shunt Qp:Qs. The Qp: Qs ratio can also be eva-luated by conventional Doppler echocardiography, but use of an additional technique is advisable. Experience in recent years has shown that the persistence of a patent foramen ovale may frequently cause cryptogenic brain infarction in young patients, particularly if associated with aneurysm of the fossa ovalis.

    We currently only perform TEE when percutaneous closure of the foramen ovale is considered as a therapeutic option.. Cor triatriatum is an uncommon heart disorder in which a membrane divides the left atrium into two chambers. The proximal chamber receives drainage from the four pulmonary veins and the distal chamber incorporates the left appendage and the atrial septum. When presence of this membrane forms a restrictive orifice joining the divided atrium, the clinical signs are similar to those of mitral stenosis but diagnosis is much harder using TTE.

    In contrast, diagnosis and assessment by TEE 15 are much easier. Thus this technique is indicated whenever this anomaly is suspected. Intra-atrial membranes in the right atrium are more common, though they are often incidental findings. They may take the form of a Chiari network, prolapse of venous valves or cor triatriatum dexter.

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    Evaluation is adequate with TTE and it is not often necessary to resort to other techniques.. Intra-atrial baffles are introduced by heart surgeons to divide the atria and redirect atrial flow. Their main application is the atrial physiological correction of transposition of the great vessels.

    Two surgical techniques are commonly used. The Mustard technique uses only prosthesis material whereas the Senning technique uses the atrial wall itself and the septum to achieve atrial division. The clinical results and the echocardiographic image obtained afterwards are similar for both techniques. The resulting septation forms a pulmonary-venous canal that directs the flow of the pulmonary veins towards the tricuspid valve and a systemic venous canal that incorporates the axis of the cavae and directs the flow of the venae cavae towards the mitral valve.

    The echocardiographic evaluation is satisfactory in most cases but when dehiscence or stenosis of the baffles is suspected, it is necessary to resort to other techniques. There is a broad range of AV valve malformations.

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    There may be two well differentiated valves or a common AV valve. One valve may be missing, perforated, hypoplastic, stenotic or insufficient. The valve may override the septum with a sub-valvular apparatus in a single ventricle or in both ventricles. In adults, malformation of papillary muscles of the mitral valve is the most common finding. It is associated with aortic coarctation and is normally incidental.

    An acute malformation may behave like a single papillary muscle causing mitral stenosis, often associated with the Shones complex. Rarely, mitral stenosis in adults can be caused by the supravalvular mitral ring or congenital fusion of the commissures.. The most common cause of congenital mitral regurgitation is an isolated anterior cleft of the mitral valve.

    Magnetic Resonance Imaging of Congenital Heart Disease

    In canal-like malformations, mitral regurgitation is caused by a similar but anatomically different malformation in which tendinous cords between the cleft and the septum cause sphincter-like function. A double mitral orifice is an uncommon malformation that also leads to valvular dysfunction.. The most common malformation of the tricuspid valve is the Ebstein anomaly. Congenital stenosis of the tricuspid valve is a rare finding, but it may appear after septation of the common AV canal. Uncorrected tricuspid atresia is an uncommon heart condition in adults, but there are increasing numbers of patients with tricuspid atresia corrected using the Fontan procedure..

    Generally, TTE with color Doppler and continuous-wave Doppler imaging allows an anatomical and functional assessment of the malformations of the AV valves. When this technique is not entirely satisfactory, TEE allows a more precise assessment of these malformations 17 Figure 7. Transesophageal echocardiography is particularly useful for intraoperative assessment when valve repairment techniques are performed. Multiple adherences of the tricuspid valve to the anterior ventricular wall hinder suitable surgical repair Figure 8.

    Transesophageal echocardiogram during systole S and diastole D in a patient with a single ventricle and hypoplasia of the tricuspid valve TV : the minimal diastolic opening of the valve arrow was not visible in the transthoracic echocardiogram. Transesophageal echocardiogram of a patient with Ebstein anomaly of the tricuspid valve TV. The septal valve is displaced towards the apex.

    The anterior valve is in its normal position and is large and hypermobile, with no adherence to the ventricular wall, allowing plastic reconstruction of the valve. When assessing AV valve malformations, cardiac catheterization and angiocardiography are only indicated in exceptional circumstances.. There are many congenital heart diseases that cannot be surgically reconstructed while still retaining the function of both ventricles. These are patients with a single anatomical or functional ventricle, including tricuspid or mitral valve atresia, an AV valve overriding tensor apparatus on either side of the septum, pulmonary or aortic atresia with hypoplasia of the underlying ventricle, complex congenital heart conditions with unbalanced ventricles, or extreme forms of the Ebstein anomaly.

    In , Glenn laid the foundations for partial bypass of the right side of the heart as a therapeutic alternative, suturing the end of the superior vena cava directly to the end of the right pulmonary artery classic Glenn anastomosis or performing an end-to-side shunt bidirectional Glenn anastomosis. In , Fontan reassessed the Glenn shunt and performed the first complete bypass of the right ventricle, connecting the right atrium to the pulmonary artery.

    During the eighties and nineties, the Fontan procedure underwent many changes and, currently, most surgeons prefer direct anastomosis of both venae cavae to the pulmonary artery total cavopulmonary connection using a lateral tunnel in the right atrium or a completely extracardiac conduit to extend the inferior vena cava.. Patients with Fontan circulation who reach adulthood are exposed to numerous complications: stenosis or narrowing of the connections or pulmonary arteries; thrombosis of the right atrium or Fontan connection; persistent or newly formed shunts; stenosis of pulmonary veins caused by the large increase in size of the right atrium; insufficiency of the AV valves; ventricular dysfunction or subaortic stenosis through partial closure of the bulboventricular foramen.

    The information provided by TEE for detecting atrial thrombosis and stenosis of the Fontan connection or pulmonary veins is much more useful 20,21 Figure 9. Magnetic resonance imaging may be indicated to assess the morphology of the main pulmonary arteries and the connection between the superior cava and the pulmonary artery.

    Heart catheterization is indicated for assessing the pressure and resistance of the pulmonary arteries before performing any further intervention.. Transesophageal echocardiogram in a patient with Fontan circulation. A: two-dimensional image revealing the atriopulmonary connection F. B: pulsed Doppler image of atriopulmonary flow with two diastolic waves short arrows. The most common congenital heart disease in new-born children is VSD but, fortunately, the defect usually closes spontaneously during the first years of life.

    Patients who reach adulthood with a VSD usually have a restrictive defect, with little left-to-right shunt and normal pulmonary pressure. In most cases, the VSD will eventually close during adulthood. Occasionally, a patient with a large VSD and pulmonary hypertension reaches adulthood with Eisenmenger syndrome, but this is currently the exception. Some patients with restrictive VSD can develop progressive subinfundibular stenosis of the right ventricle double chamber right ventricle as adults. Others develop aortic valve regurgitation, fixed subaortic stenosis or tricuspid regurgitation.

    Infectious endocarditis is a relatively frequent complication that may affect the mural endocardium, the aortic valve or the tricuspid valve.. All patients with VSD should be monitored with clinical examinations and echocardiographs while the shunt remains open. Transthoracic echocardiography with color Doppler imaging is an excellent technique for determining the anatomical position of the VSD perimembranous, trabecular, inlet septal, subarterial or ventriculoatrial , the size of the defect, the magnitude of the shunt and the systolic pressure of the right ventricle and pulmonary artery.

    This technique is also very useful for early detection of possible complications. Transesophageal echocardiography and MRI are used only in patients with a very poor transthoracic view or when conventional echocardiography does not provide detailed information on the complications aortic or tricuspid regurgitation mechanism, suspicion of endocarditis not shown by TTE.

    Nuclear angiocardiography should be performed In patients with mo-derate left-to-right shunt to quantify the Qp:Qs ratio.. Cardiac catheterization is indicated in patients with high pulmonary blood pressure for determination of the vascular pulmonary resistance and response to vasodilators. Residual shunts are sometimes detected with Doppler color imaging in patients who have previously undergone an intraventricular patch operation. The shunt is usually restrictive, but it may increase over time. The patch may retract and become calcified making anatomical assessment of the defect difficult, but Doppler color imaging is not affected.

    When the patch is large, the direction of the shunt may be extremely diverse interventricular, ventriculoatrial or aortoventricular ; nevertheless, most cases can be assessed by TTE.. In congenital heart diseases, as in acquired heart disease, ventricular function is the main prognostic factor, but in congenital heart diseases, pulmonary ventricular function is as important as systemic ventricular function. Moreover, the systemic ventricle may have left, right or indeterminate morphology, which makes assessment of ventricular function more difficult.

    The left ventricle is recognized by its smooth-wall structure and the right by its trabecular structure, but the main defining feature is the morphology of the AV valve. When there are two ventricles, the right one is always connected to the tricuspid valve and the left to the mitral valve. When a double-inlet ventricle is present, the morphology is left if it has an outlet chamber and right if both arterial vessels leave the main ventricle. Echocardiographic assessment of left ventricular function is the same in congenital heart disease and acquired heart disease, but echocardiographic assessment of right pulmonary or systemic ventricular function in congenital heart disease is much more difficult.

    The complicated structure of the right ventricle does not allow direct quantitative determination of the ejection fraction, though subjective visual estimation of systolic function is just as valid. Parameters that measure the diastolic diameter of the inflow tract, systolic shortening of the area in the plane of the four cardiac chambers, the global ventricular function Tei index or total internal diameter of the tricuspid ring are all useful for quantifying right ventricular function.

    However other techniques are often necessary to determine the ejection fraction and ventricular volumes. Equilibrium radionuclide ventriculography is a method that has been shown to be of great use for determining the volumes and function of the right ventricle, 24 though the most reliable method currently in use is MRI. Obstruction of the outflow tract of the left ventricle may be valvular, subvalvular or supravalvular. Transthoracic echocardiography can usually suffice for locating the obstruction and determining its morphology, and continuous Doppler imaging allows the maximum instantaneous gradient and the mean gradient at the obstruction to be determined.

    Occasionally, patients with fixed subaortic stenosis with marked septal hypertrophy require TEE to differentiate localized subaortic stenosis from obstructive hypertrophic myo-cardiopathy 27 and, in some patients with aortic supravalvular stenosis, MRI 28 allows the morphology of the obstruction and the ascending aorta to be determined..

    Aortic valve regurgitation is also assessed by conventional echocardiography with color Doppler imaging. Nevertheless, in patients who are to undergo surgery preserving the valve, TEE provides more information on the functional anatomy of the aortic root and the regurgitation mechanism dilatation of the sinotubular junction, asymmetry of the sinuses, valvular prolapse and tenting, leaflet retraction or perforation.

    As in the left ventricle, obstruction of the right outflow tract may have a valvular, subvalvular or supra-valvular position. Normally, pulmonary valve stenosis can be accurately assessed with TTE and continuous Doppler imaging, though the assessment of subvalvular or supravalvular obstruction may be more difficult.

    Subvalvular obstruction may affect the infundibulum excessive hypertrophy or infundibular hypoplasia or be subinfundibular. This latter case appears occasionally in adults with VSD because hy-pertrophy of the septomarginal bands can cause ventricular obstruction, dividing the right ventricle into two chambers double-chambered right ventricle.