Heart Failure, Magnetic Resonance, Microvascular Dysfunction, Univentricular Heart
Conditions
Keywords
Fontan circulation, CMR, stress-perfusion, tissue characterization, univentricle heart, TCPC
Brief summary
Univentricular heart (UVH) is a severe congenital heart disease. Accurate advanced non-invasive diagnostic methods is limited. Cardiovascular magnetic resonance (CMR) imaging has evolved as a particularly useful tool for the study of patients with adult congenital heart disease (ACHD) considering its ability to determine detailed anatomy and detect early cardiac dysfunction without the need for radiation exposure. Most of contemporary treatment recommendations are based on consensus opinions/documents and small studies from local, or national registries. Improved knowledge is needed in all these areas to facilitate clinical decisions regarding treatment, monitoring and follow-up. This study seeks to answer if early detection of deterioration in cardiac function, venous pressure and microvascular dysfunction can identify patients before the symptoms progress and thus help to initiate early treatment. The hypothesis is that quantitative myocardial stress-perfusion maps improves the pathophysiological insight in patients with UVH. The overall goal with this research proposal is to implement combined advanced CMR imaging for a comprehensive non-invasive mapping of functional cardiovascular behavior in patients with complex UVH disease. The outcome of this research may benefit this young adult patient population due to early detection of cardiac disease, less hospitalizations because of heart failure, and eventually decrease morbidity and mortality.
Detailed description
CMR is performed supine with a Magnetom Aera® 1.5 Tesla (T) scanner (Siemens Healthcare, Erlangen, Germany), with a phased-array 18-channel body matrix coil and a spine matrix coil. A venous blood sample is drawn to determine hematocrit and blood creatinine prior to imaging. Full coverage retrospective electrocardiographic (ECG)-gated balanced steady state free precession (bSSFP) cine imaging is acquired in standard three long-axis and short-axis slices. Typical imaging parameters are flip angle 68°, pixel size 1.4 × 1.9 mm2, slice thickness 8.0 mm, echo time (TE)/repetition time (TR) 1.19/37.05 ms, matrix size 256 × 144 and field of view (FOV) 360 × 270 mm2. Using first-pass perfusion imaging, quantitative perfusion maps (ml/min/g) are acquired in one short-axis and one long-axis slice (mid-ventricular, 2-chamber) during administration of an intravenous contrast-agent bolus (0.05 mmol/kg, gadobutrol, Gadovist, Bayer AB, Solna, Sweden), during adenosine infusion (110 µg/kg/min or increased according to clinical routine to 140 µg/kg/min in the absence of adequate response to adenosine (Adenosine, Life Medical AB, Stockholm) and in subsequent rest. Adenosine response is assessed clinically based on symptoms and heart rate response. Adenosine and contrast agent are administered in two different cannulas. Subjects abstained from caffeine for 24 hours prior to CMR examination. A distributed tissue exchange model is used to compute the perfusion maps and the Gadgetron (reconstruction computer) inline perfusion mapping software is used to generate the perfusion maps.Typical imaging parameters were bSSFP single shot readout, flip angel 50°, slice thickness 8.0 mm, TE/TR 1.04/2.5 ms, bandwidth 1085 Hz/pixel, FOV 360 × 270 mm2 and saturation delay/trigger delay (TD) 95/40 ms.
Interventions
DIAGNOSTIC_TESTCardiac magnetic resonance stress-perfusion
Included patients will be examined at the Karolinska University Hospital in a 1.5T Siemens Sola magnetic resonance camera at rest and during adenosine stress with specific CMR sequences (adenosine stress-perfusion, myocardial velocities, and tissue characterization) for non-invasive determination of macro- and microvascular dysfunction, global myocardial function, pulmonary artery pressure and scarring of the myocardium. Adenosine or Regadenoson will be used as stress medication which is according to clinical routine. Adenosine will be infused over approximately 5 minutes (110-140 μg / kg/min), Regadenoson (5 ml) will be a 10-second injection (400 μg single dosage). Intravenous gadolinium-based contrast agents will be administered, Gadovist (1 mmol/ml, gadobuterol), 0.15 mmol/kg during stress and rest.
Sponsors
Karolinska University Hospital
Karolinska Institutet
Study design
Observational model
COHORT
Time perspective
PROSPECTIVE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Patients who had undergone total cavo-pulmonary connection (TCPC) surgery resulting in Fontan circulation. * NYHA (New York Heart Assosiation) class I-II. * Understanding the study information (signed informed consent). * \>18 years old.
Exclusion criteria
* Device therapy (pacemaker, ICD). * Failing Fontan (NYHA III-IV). * Kidney failure (GFR\<30ml/h). * Arrythmia (atrial fibrillation). * Pregnancy.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Detection of microvascular dysfunction in patients with UVH | Through study completion, an average of 1 year | This project aims to evaluate microvascular dysfunction using quantitative stress-perfusion CMR in patients with different morphological systemic chamber (left vs right). |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| To detect and compare tissue characterization. | Through study completion, an average of 1 year | Investigate whether positive findings in tissue characterization is higher in different systemic ventricles (left vs right) using T1 and T2-mapping, LGE (late gadolinium enhancement, myocardial scar). |
Other
| Measure | Time frame | Description |
|---|---|---|
| Venous pressure in TCPC | Through study completion, an average of 1 year | Calculate venous delta pressure (customized in-house software) in the cavo-pulmonary connection using CMR 4D-flow imaging. |
Countries
Sweden
Contacts
Primary ContactPeder Sorensson, MD, Associate professor
Backup ContactAyse-Gul Ozturk, MD
Outcome results
None listed