Cardiovascular MR Imaging after Surgical Correction of Tetralogy of Fallot: Approach Based on Understanding of Surgical Procedures
Open accessAbstract
Tetralogy of Fallot (TOF) is one of the most common congenital heart diseases for which patients are referred for postoperative magnetic resonance (MR) imaging evaluation. The most common surgical procedures for TOF repair include infundibulectomy, transannular pulmonary artery patch repair, and right ventricle-pulmonary artery conduit placement. In the past few decades, surgery has proved successful, but most patients require repeat imaging throughout their lives. MR imaging is now frequently used for morphologic and functional evaluation after TOF repair. The most common late postoperative sequelae and residual lesions include right ventricular outflow tract aneurysm and dyskinesis, conduit failure, pulmonary regurgitation, tricuspid regurgitation, right ventricular failure, residual main and branch pulmonary artery stenosis, branch pulmonary artery aneurysm, left pulmonary artery kinking, and residual or recurrent ventricular septal defect. The imaging approach for the evaluation of patients with repaired TOF should be guided by the surgical procedure used and the complications that are expected. Knowledge of the most common postoperative problems and their cardiovascular MR imaging appearances is essential for good radiology practice in this clinical setting.
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The growth of pulmonary regurgitation is one of the main drawbacks of transannular patch repair.
“The growth of PR is one of this procedure’s main drawbacks.”
From Multimodality imaging assessment of tetralogy of Fallot: From diagnosis to long-term follow-up (2023) · cites this paper as [47]
On cine images, a transannular patch appears as an akinetic or dyskinetic zone.
“On the cine pictures, the transannular patch appears as an akinetic or dyskinetic zone.”
From Multimodality imaging assessment of tetralogy of Fallot: From diagnosis to long-term follow-up (2023) · cites this paper as [47]
Severe RVOT aneurysms can lead to insufficient RV circulation.
“Severe RVOT aneurysms can lead to insufficient RV circulation.”
From Multimodality imaging assessment of tetralogy of Fallot: From diagnosis to long-term follow-up (2023) · cites this paper as [47]
Right ventricular dilatation and dysfunction can result from various factors such as pulmonary regurgitation, tricuspid regurgitation, RVOT aneurysm, and fibrosis of the RV-free wall.
“This can result from various factors such as PR, TR, RVOT aneurysm, and fibrosis of the RV-free wall.”
From Multimodality imaging assessment of tetralogy of Fallot: From diagnosis to long-term follow-up (2023) · cites this paper as [47]
The best way to quantify tricuspid regurgitation is RVSV minus pulmonary forward flow divided by 100.
“The best way to quantify the TR is RVSV—pulmonary forward flow/100.”
From Multimodality imaging assessment of tetralogy of Fallot: From diagnosis to long-term follow-up (2023) · cites this paper as [47]
On CMR cine images, the anterior RVOT wall appears thinned, and pulmonary regurgitation can be visually assessed.
“The anterior RVOT wall is seen to be thinned on CMR cine pictures, and PR can be visually assessed.”
From Multimodality imaging assessment of tetralogy of Fallot: From diagnosis to long-term follow-up (2023) · cites this paper as [47]
Tricuspid regurgitation can be associated with pulmonary regurgitation and can indicate the progress of PR or RV dilatation.
“TR can be associated with PR. It is important to monitor it in the presence of PR, as it can indicate the progress of PR or RV dilatation.”
From Multimodality imaging assessment of tetralogy of Fallot: From diagnosis to long-term follow-up (2023) · cites this paper as [47]
Using PC sequences, the pulmonary regurgitant fraction can be measured.
“Using PC sequences, the regurgitant fraction can be measured.”
From Multimodality imaging assessment of tetralogy of Fallot: From diagnosis to long-term follow-up (2023) · cites this paper as [47]
CMR cine images and post-gadolinium LGE images can visualise RVOT aneurysm and surrounding fibrosis, respectively.
“CMR cine images and post-gadolinium LGE images can visualise, respectively, the aneurysm and surrounding fibrosis [46,47,48].”
From Multimodality imaging assessment of tetralogy of Fallot: From diagnosis to long-term follow-up (2023) · cites this paper as [47]
An RVOT inplane cine can be useful for visual estimation of pulmonary regurgitation together with other sequences.
“For a visual estimation of PR, an RVOT inplane cine can be useful together with other sequences [46,47,48].”
From Multimodality imaging assessment of tetralogy of Fallot: From diagnosis to long-term follow-up (2023) · cites this paper as [47]
In the absence of shunts, the stroke volumes of both ventricles are equal.
“In the absence of shunts, the stroke volumes of both ventricles are equal.”
From Multimodality imaging assessment of tetralogy of Fallot: From diagnosis to long-term follow-up (2023) · cites this paper as [47]
Residual RVOT stenosis is the most common late complication after infundibulectomy.
“Residual RVOT Stenosis: The most common late complication after infundibulectomy.”
From Multimodality imaging assessment of tetralogy of Fallot: From diagnosis to long-term follow-up (2023) · cites this paper as [47]
Residual RVOT stenosis leads to right ventricular hypertrophy, exercise intolerance, and arrhythmias.
“It leads to right ventricular hypertrophy (RVH), exercise intolerance, and arrhythmias.”
From Multimodality imaging assessment of tetralogy of Fallot: From diagnosis to long-term follow-up (2023) · cites this paper as [47]
CMR cine bSSFP sequences can identify residual RVOT stenosis and right ventricular hypertrophy.
“CMR cine bSSFP sequences can identify stenosis and RVH.”
From Multimodality imaging assessment of tetralogy of Fallot: From diagnosis to long-term follow-up (2023) · cites this paper as [47]
CMR cine images and volumetry assessment quantify RV dilatation and low ejection fraction.
“CMR cine images and volumetry assessment quantify RV dilatation and low ejection fraction [46,47,48].”
From Multimodality imaging assessment of tetralogy of Fallot: From diagnosis to long-term follow-up (2023) · cites this paper as [47]
Pulmonary regurgitation is a common complication following repair of TOF and can have negative effects on the RV, leading to RV dilatation and a negative coupling effect.
“PR is a common complication following the repair of TOF, and it can have negative effects on the RV, leading to RV dilatation and a negative coupling effect.”
From Multimodality imaging assessment of tetralogy of Fallot: From diagnosis to long-term follow-up (2023) · cites this paper as [47]
Bright portions of a transannular patch on post-gadolinium LGE images are due to localised fibrosis.
“Additionally, portions of the patch that are bright on post-gadolinium LGE pictures are a result of localised fibrosis [44,45,46,47].”
From Multimodality imaging assessment of tetralogy of Fallot: From diagnosis to long-term follow-up (2023) · cites this paper as [47]
CMR evaluation allows for the visualisation of small VSDs.
“CMR evaluation allows for the visualisation of small VSDs [46,47,48].”
From Multimodality imaging assessment of tetralogy of Fallot: From diagnosis to long-term follow-up (2023) · cites this paper as [47]
Cine pictures reveal dephasing jets over a VSD to evaluate the shunt, and CMR aids in assessing the integrity of the VSD patch.
“Cine pictures reveal dephasing jets over the VSD to evaluate the shunt, and CMR aids in assessing the integrity of the VSD patch.”
From Multimodality imaging assessment of tetralogy of Fallot: From diagnosis to long-term follow-up (2023) · cites this paper as [47]
Cine images can identify main pulmonary artery and pulmonary artery anomalies, although metallic material such as stents in PAs or prosthetic valves is a significant limitation.
“Cine images can identify MPA and PA anomalies, although a significant limitation can be represented by the presence of metallic material (stents in PAs, prosthetic valves) [46,47,48].”
From Multimodality imaging assessment of tetralogy of Fallot: From diagnosis to long-term follow-up (2023) · cites this paper as [47]
Left ventricular dysfunction is a predictor of poor outcomes in repaired TOF.
“Left Ventricular Dysfunction: This is a predictor of poor outcomes.”
From Multimodality imaging assessment of tetralogy of Fallot: From diagnosis to long-term follow-up (2023) · cites this paper as [47]
Estimating Qp:Qs can be used to determine the importance of a shunt.
“Estimating Qp:Qs (pulmonary/systemic output) can be used to determine the importance of the shunt.”
From Multimodality imaging assessment of tetralogy of Fallot: From diagnosis to long-term follow-up (2023) · cites this paper as [47]
Cine images show global hypokinesia of the LV with decreased LV ejection fraction, and LGE can reveal scar secondary to previous surgery or coronary artery disease.
“Cine images show global hypokinesia of the LV with a decreased LV ejection fraction. LGE can reveal the presence of a scar, which can be secondary to previous surgery (pulmonary artery vent or surgical emboli) or coronary artery disease [46,47,48].”
From Multimodality imaging assessment of tetralogy of Fallot: From diagnosis to long-term follow-up (2023) · cites this paper as [47]
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Total repair of tetralogy of Fallot
Tatco, V. R., Campos, A., & Hacking, C. (2016) · Radiopaedia.org · doi:10.53347/rid-43857
MRI in the assessment of congenital heart disease
Deshpande, A. (2018) · Applied Radiology · doi:10.37549/ar2456
An Imager's Overview to Transcatheter Pulmonic Valve Replacement
Truesdell, W. R., Salavitabar, A., Zampi, J. D., Agarwal, P., & Joshi, A. (2023) · Seminars in Roentgenology · doi:10.1053/j.ro.2023.11.008
Ayyad, M. (2024) · The Medical Journal of Cairo University/The Medical Journal of Cairo University · doi:10.21608/mjcu.2024.353097
Can pulmonary artery morphology influence the differential pulmonary flow?
Ayyad, M. S., & Ramadan, Z. A. (2026) · The Egyptian Journal of Radiology and Nuclear Medicine · doi:10.1186/s43055-026-01817-w
- Authors
- Ordovas, K. G., Muzzarelli, S., Hope, M. D., Naeger, D. M., Karl, T., Reddy, G. P., Marchiori, E., & Higgins, C. B.
- Affiliations
- University of California, San Francisco (US)
- Mater Children's Hospital (AU)
- Universidade Federal do Rio de Janeiro (BR)
- Venue
- RadioGraphics
- Published
- 2013-07
- Volume
- 33
- Issue
- 4
- Pages
- 1037-1052
- ISSN
- 0271-5333 (ISSN-L)
- 1527-1323
- OpenAlex
- W2162505053
- Cited by
- 26
- References
- 47
- Citations by year
- 2026: 1 · 2025: 1 · 2024: 3 · 2023: 2 · 2022: 2 · 2021: 1 · 2020: 6 · 2018: 3 · 2017: 1 · 2016: 4 · 2015: 2
- FWCI
- 1.45
- Type
- journal article
- Language
- en
- Open access
- green
- escholarship.org
- Locations
- Radiographics (publishedVersion)
- PubMed (publishedVersion)
- Zurich Open Repository and Archive (University of Zurich) (acceptedVersion)
- eScholarship (California Digital Library) (submittedVersion)
- Zurich Open Repository and Archive (University of Zurich) (submittedVersion)
- Topics
- Health Sciences › Medicine › Epidemiology › Congenital Heart Disease Studies
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Valve Diseases and Treatments
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Cardiac Imaging and Diagnostics
- Keywords
- tetralogy of Fallot, right ventricle to pulmonary artery conduit, right ventricular outflow tract aneurysm, pulmonary regurgitation, tricuspid regurgitation, pulmonary artery stenosis, pulmonary artery aneurysm, ventricular septal defect, congenital heart disease
- MeSH terms
- Humans, Magnetic Resonance Imaging, Postoperative Care, Prognosis, Radiography, Cardiovascular Surgical Procedures, Tetralogy of Fallot, Treatment Outcome, Plastic Surgery Procedures, Surgery, Computer-Assisted
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