p.15 抽出テキスト
............................................................... development of signs of heart failure. An electrocardiogram (ECG) and pulse oximetry are routinely carried out alongside clinical examination. A chest X-ray provides information on changes in heart size and configuration, as well as pulmonary vascularization. Noninvasive imaging is routinely performed by transthoracic echocardiography (TTE) involving transoesophageal echocardiography (TOE) and cardiovascular magnetic resonance (CMR) imaging where indicated. Thus, patients with CHD may particularly benefit from magnetic resonance-conditional/compatible pacemakers and defibrillators. Echocardiography is superior to CMR in estimating pressure gradients and pulmonary artery (PA) pressure (PAP), and detecting small, highly mobile structures such as vegetations. CMR is ideal for accurate quantification of ventricular volumes, ejection fraction (EF), valvular regurgitation,15 calculation of pulmonary and systemic blood flow, and myocardial fibrosis assessment. Cardiovascular computed tomography (CCT) with modern single or dual source scanners can be performed with dose-saving protocols and may be required for special indications as indicated in Table 6. Interdisciplinary expert collaboration is important: imaging CHD experts need to respond to feedback from CHD surgeons, interventionalists, and electrophysiologists to optimize imaging contribution to care, as well as work with each other to enhance appropriate use of multimodality imaging. Advanced imaging is usually best reserved for when patients are seen in the specialist centre rather than be repeated. Echocardiography, CMR, and CCT require staff with expertise in CHD as well as in imaging, which has training and resource implications. Within the ESC, this is recognized by a certification examination of the European Association of Cardiovascular Imaging (EACVI), separate from the standard TTE, TOE, or CMR examination, and specific to CHD. 3.3.1 Echocardiography Echocardiography remains the first-line imaging modality.16 M-mode, two-dimensional, and three-dimensional (3D) echocardiography are all used for imaging, whereas tissue Doppler imaging and deformation imaging, especially longitudinal strain and strain rate, are becoming integral parts of functional assessment.17 Echocardiography provides information on cardiac anatomy, situs (including orientation and position of the heart), connection of the atria and ventricles, heart valves, and connection of ventricles with the great arteries. For assessment of morphology and function of cardiac valves, TTE and, if necessary, TOE (nowadays often combined with 3D echocardiography), is the preferred imaging modality. This is also true for shunt lesions, such as ASDs or ventricular septal defects (VSDs): 3D echocardiography enables an en face view, which can be helpful in the assessment of the size and shape of a defect and its relation to surrounding structures. Ventricular size, shape, volume, and EF can be measured and calculated with TTE. Signs of volume overload, in the case of a shunt or valvular regurgitation, or pressure overload, in the case of increased afterload, are detected in a good-quality TTE. Even older techniques using M-mode for measurement of tricuspid annular plane systolic Table 5 Staff requirements for specialist ACHD centresa Discipline Required number Adult/paediatric cardiologist with ACHD certification >_2 ACHD imaging specialist (certified in TTE/TOE, CMR, CCT) >_2 Congenital interventional cardiologist >_2 CHD surgeon >_2 Anaesthesiologist with CHD experience and expertise >_2 Specialist nurse (if national professional nursing bodies allow specialization) >_2 Invasive electrophysiologist with ACHD experience >_1 Pulmonary vascular disease expert >_1 Clinical geneticist >_1 Psychologist >_1 Social worker >_1 Palliative care team ACHD = adult congenital heart disease; CHD = congenital heart disease; CMR = cardiovascular magnetic resonance; CCT = cardiovascular computed tomography; TOE = transoesophageal echocardiography; TTE = transthoracic echocardiography. aModified from Baumgartner et al.8 Table 6 Indications for cardiovascular magnetic resonance imaging in ACHD patients Indications for CMR in ACHD patients • Quantification of RV volumes, EF (including subpulmonary RV, sys- temic RV, and single ventricle) • Evaluation of RVOTO and RVPA conduits • Quantification of PR • Evaluation of PAs (stenoses, aneurysms) and the aorta [aneurysm, dissection, coarctation (CCT may be superior)] • Evaluation of systemic and pulmonary veins (anomalous connection, obstruction, coronary venous anatomy pre-procedure, etc.) • Collaterals and arteriovenous malformations (CCT may be superior) • Coronary anomalies and CAD (CCT is superior for intramural course, slit-like course, acute angle take-off, myocardial bridging, and plaque assessment) • Detection and quantification of myocardial ischaemia by CMR stress perfusion • Evaluation of intra- and extracardiac masses • Quantification of myocardial mass (LV and RV) • Detection and quantification of myocardial fibrosis/scar (late gadolinium enhancement, T1 mapping) tissue characterization (fibrosis, fat, iron, etc.) • Quantification of systemic and pulmonary blood flow to calculate Qp:Qs • Quantification of perfusion distribution to the right/left lung • Measurement of pulmonary blood flow in patients with multiple sour- ces of blood supply (i.e. with major aorto-pulmonary collateral arteries) ACHD = adult congenital heart disease; CAD = coronary artery disease; CMR = cardiovascular magnetic resonance; CCT = cardiovascular computed tomography; EF = ejection fraction; LV = left ventricle/ventricular; PA = pulmonary artery; PR = pulmonary regurgitation; Qp:Qs = pulmonary to systemic flow ratio; RV = right ventricle/ventricular; RVOTO = right ventricular outflow tract obstruction. Downloaded from academic.oup.com/eurheartj/article/42/6/563/5898606 by guest on 07 October 2026