A 30-year-old patient presented with features of biventricular
failure and PAH, with upper body hypertension, differential
cyanosis, and differential clubbing.
Patient subsequently underwent bare-metal stenting of the
coarctation, leaving PDA open. Post-stenting CMR showed
mild increase in Qp:Qs to 1.2:1, with an increment of 34% in
absolute pulmonary blood flow and moderate improvement
in biventricular volumes and function.
Cine 2D FIESTA demonstrated a large PDA shunting
bi-directional with a tight pre-ductal coarctation of
Aorta and severe biventricular systolic dysfunction.
3D MR angiography showed the complex relationship
between the PDA and coarctation (Figures 8, 9).
Phase contrast flow/time graphs showed a pattern of PAH
in both lungs, with lower flows in the right lung and Qp:Qs
of 0.9:1 (Figure 10). PDA showed a systolic right-to-left shunt
and a pan-diastolic left-to-right shunt (net flow being about
In this case, CMR clearly showed the complex anatomy of
PDA and aortic coarctation. In addition, the Cine images and
phase contrast flow study provided the detailed physiology
of circulation in the pulmonary arteries and aorta, which
was used to guide further treatment plans.
Cardiac MR is a useful tool in establishing morphological
diagnosis in complex congenital heart diseases. A combination
of CMR tools such as Cine (SSFP) images, MR angiography,
and phase contrast (flow) studies allow unique insight into
patterns and physiology of CHD-PAH. CMR also overcomes
the shortcomings of cardiac catheterization in accurately
assessing shunts and differential pulmonary blood flow in
complex cardiac lesions with PAH.
Mahesh Kappanayil, FNB,
is an Associate Professor at Amrita Institute
of Medical Sciences.
Ramiah Rajesh Kannan, MD, DNB, PDCC, is Associate Professor at Amrita Institute of Medical Sciences. He has more than five years of experience in cardiac
imaging and has performed more than 5,000 cardiac C T angiography scans (adult coronary and CHD) and more than 500 cardiac MRI exams.
Mahesh Kappanayil, FNB, is an Associate Professor at Amrita Institute of Medical Sciences. He completed his medical graduation (MBBS) from University of
Delhi in 1995, and subsequently his residency in Pediatrics. He completed his post-doctoral fellowship in Pediatric Cardiology from Amrita Institute of Medical
Sciences (AIMS), Kochi, Kerala, which is one of the leading pediatric cardiac care centers in Asia. He has continued as a faculty member at AIMS since completion
of his fellowship in 2006.
Amrita Institute of Medical Sciences in Cochin Area, India brings together a dedicated team of physicians, nurses, and other healthcare professionals to
provide the highest standards of medical treatment. The full range of primary and specialty care medical services enables cross-specialty consultation, which
assures outstanding treatment for each patient. The extensive infrastructure offers extensive facilities comprising 25 modern operating theatres, 210 equipped
intensive-care beds, a fully computerized and networked Hospital Information System, a fully digital radiology department, a 24/7 telemedicine service, and
a NABL accredited clinical laboratory.