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Optimized Computed Tomography Angiography Protocol for the Evaluation of Thrombus in Patients with Fontan Anatomy
Ryan Boggs1, Tavenner Dibert2, Jennifer Co-Vu2
1Department of Pediatrics, Congenital Heart Center, University of Florida, 1600 SW Archer Road, PO BOX 100297, Gainesville, FL, 32610, USA. Rboggs@peds.ufl.edu.
Insights
A biphasic computed tomography angiography (CTA) protocol improves the ability to identify critical structures in the Fontan circuit for evaluating thromboembolic disease in single-ventricle patients. This method offers greater diagnostic capability than traditional monophasic CTA protocols.
Area of Science:
- Cardiology
- Radiology
- Pediatric Surgery
Background:
- Patients with single-ventricle physiology often undergo the Fontan procedure, placing them at high risk for thromboembolic disease.
- Chest computed tomography angiography (CTA) is used to evaluate this risk, but unusual flow patterns can lead to false positives.
- Accurate visualization of the Fontan circuit is crucial for reliable thromboembolic disease assessment.
Purpose of the Study:
- To evaluate the capability of a biphasic CTA protocol in clearly identifying critical Fontan circuit structures.
- To compare the diagnostic performance of biphasic CTA versus monophasic CTA for detecting Fontan thromboembolic disease.
Main Methods:
- Retrospective review of 46 chest CTA scans from 21 Fontan patients (2011-2017).
- Two independent pediatric cardiologists assessed CTA scans for clarity of 5 critical Fontan circuit structures, assigning a score (0-5).
- Scans were categorized as not capable (0-2), partially capable (3-4), or capable (5) for clear identification.
Main Results:
- The biphasic CTA protocol demonstrated a higher capability (62.5%) in clearly identifying all 5 critical structures compared to the monophasic protocol (27%).
- This difference was statistically significant (p=0.027).
- The biphasic protocol showed improved diagnostic capability for Fontan thromboembolic disease detection.
Conclusions:
- The single-site biphasic CTA protocol offers superior diagnostic capability for Fontan thromboembolic disease compared to the monophasic protocol.
- This enhanced visualization aids in more accurate assessment of thromboembolic risk in Fontan patients.
- Further prospective studies are recommended to validate these findings.
Abstract:
The Fontan procedure is the final stage in the palliative surgical approach to patients with single-ventricle physiology. These patients have an increased risk for thromboembolic disease in the Fontan circuit, which can be evaluated by chest computed tomography angiography (CTA) in acute settings. However, false-positive results are common secondary to unusual streaming patterns in the Fontan circuit. A biphasic CTA protocol was evaluated for the capability to clearly identify structures of the Fontan circuit that are critical for the evaluation of thromboembolic disease. The study was a retrospective chart review of Fontan patients with a chest CTA scan obtained between 2011 and 2017. Two pediatric cardiologists with additional training in cardiac CT imaging independently reviewed each CTA and awarded one point for each of 5 Fontan circuit structures clearly identified resulting in a score range of 0-5. A score of 0-2 considered not capable, 3-4 partially capable, and 5 capable to clearly identify critical structures of the Fontan circuit. During the study period, 46 CTA scans were performed on 21 patients. Of the CTA scans using a biphasic protocol, 62.5% (10/16) were considered capable to clearly identify all 5 critical structures of the Fontan circuit vs 27% (8/30) of the CTA scans using a monophasic protocol (p = 0.027). Overall our results suggest that the single-site biphasic CTA protocol has greater diagnostic capability to detect the presence of Fontan thromboembolic disease when compared to the more traditional monophasic CTA protocol. Future prospective studies are needed to confirm these findings.
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