Protocols for cardiac magnetic resonance in children

«Von Äpfeln und Birnen» – oder: Warum Krankengeschichte nicht gleich Krankengeschichte ist

Bull Med Suisses. 2005;86(12):718–720

Leiter Fachkommission Unabhängige Beschwerdestelle für das Alter ZH/SH, PD für geriatrische Neurologie Universität Zürich

Publié le 23.03.2005

Position paper of a group of Swiss pediatric and adult cardiologists and radiologists performing cardiac magnetic resonance in congenital heart disease, endorsed by the working groups “Adult Congenital Heart Disease (WATCH)” and “Echocardiography and Cardiac Imaging” of the Swiss Society of Cardiology, the Swiss Society of Pediatric Cardiology and the “Ressort Cardiac Imaging” of the Swiss Society of Radiology
Tobias Rutza*, Kerstin Wustmannb*, Milan Prsac, ­Jean-Paul Valléd, Birgit Donnere, Jens Bremerichf, Christina Deluigib, OHNE HYPERLINK: g.tamburello@­

1. Introduction

This document has been written by pediatric and adult cardiologists as well as radiologists with expertise in the field of congenital heart disease (CHD) imaging of the five university hospitals in Switzerland. Cardiac magnetic resonance (CMR) is one of the basic imaging modalities for assessment of CHD with increasing use. This document aims to harmonize imaging protocols and seeks high quality and comparability of CMR examinations between centers treating pediatric and adult CHD patients in Switzerland.
The document summarizes in a first part (sections 2 to 7) general and technical aspects of CMR in CHD. The second part (section 8) provides protocols for the most common CHD defects based on current guidelines and position pap ers.1-4 We define for every lesion the standard of a comprehensive CMR examination by describing the mandatory and optional sequences that should be acquired. However, every center is free to expand the protocols according to patients` individual clinical situation and indications as well to address center specific issues. This document does not replace standard CMR textbooks or international guidelines published e.g. by the Society of Cardiac Magnetic ­AUTOMATISCHER HYPERLINK:
Abbreviations: Aao = ascending aorta, BCPC = bidirectional cavopulmonary connection, CE MRA = contrast enhanced magnetic resonance angiography, CHD = congenital heart disease, CMR = cardiac magnetic resonance, Dao = descending aorta, GA = general anesthesia, GBCA = gadolinium-based contrast agent, ICD = implantable cardioverter-defibrillator, IVC = inferior vena cava, LPA = left pulmonary artery, MPA = main pulmonary artery, LV = left ventricle, PC CMR = phase contrast cardiac magnetic resonance, PA = pulmonary artery, PM = pacemaker, PR = pulmonary regurgitation, RPA = right pulmonary artery, RV = right ventricle, SVC = superior vena cava, SSFP = steady state free precession, T = Tesla, TI = inversion time, Venc = velocity encoding
Tabelle 1: Metaanalyse von Risikofaktoren für Betagten­misshandlung [3].
RisikofaktorenOdds-Ratio mit 25. und 75.Percentile
Risikofaktoren von Seiten 
der Betroffenen 
Psychische Probleme3,3; 1,5–7,1
Verhaltensstörungen bei somatisch ­Pflegebedürftigen2,3; 1,6–3,2
Verhaltensstörungen bei Demenz 38.3, 4,6–326
Pflegebedürftigkeit 4,4; 2,4–7,9
Gebrechlichkeit4,8; 3,3–7,8
Risikofaktoren von Seiten 
der Misshandelnden 
Hoher Betreuungsstress resp. Belastung1,8; 1,2–2,7
Eigene psychische Krankheit oder 
Probleme wie Sucht 3,1; 1,4–7,1
Risikofaktoren von Seiten der Familienbeziehung 
Konfliktreiche Beziehung9,0; 4,8–16,8
Risikofaktoren von Seiten der Umwelt 
Grosse soziale Unterstützung von aussen (gute soziale Unterstützung von aussen reduziert das Misshandlungsrisiko 
massiv)0,4; 0,2–1,07
Geringe soziale Unterstützung 
von aussen bei Pflegebedürftigkeit 4,6; 2,4–8,9

2. Specific aspects for infants and small children

In children younger than 7 years of age, CMR usually needs to be performed under sedation or GA. However, in neonates and infants under 6 months of age, a successful examination can also be performed without sedation or GA using the “feed and wrap” technique.5 CMR in infants and small children poses technical challenges due to the small size of the structures and rapid heart rates, requiring sequence optimization.6 A high spatial resolution can be achieved by using thin slices, a small field of view, and a large matrix. To maintain a high signal to noise ratio, smaller multielement coils and multiple signal averages are often necessary. Achieving a high temporal resolution requires decreasing the number of views per segment. For CE MRA in infants, the small volumes of contrast used are best injected by hand (injection during 80% of scan time).

3. Safety Aspects

3.1 General

Common contraindications for CMR have to be respected (claustrophobia, non-CMR compatible neurostimulators, insulin-pumps and epidural pumps, etc.)

3.2 Gadolinium-based contrast agents (GBAC)

GBCAs are generally safe, however a few restrictions and contraindications exist and have to be respected.7 Major adverse events are very rare and consist of allergic reactions and the nephrogenic systemic fibrosis.7 Nephrogenic systemic fibrosis is an exceedingly rarely reported generalized disease. Risk is increased in patients with a severely decreased renal function and a glomerular filtration rate below 30ml/min. More recently, deposition of Gadolinium in the brain has been reported in patients who underwent repeated magnetic resonance imaging (>5) for various (non-cardiac) indications; the clinical significance of this finding is not known yet. In general, if administration of GBCAs is required, such as for angiography, perfusion studies or late gadolinium enhancement, the use of non-linear, cyclic GBCAs is preferred, as for this group of contrast agents no or very few cases of nephrogenic systemic fibrosis have been reported and brain deposition may be less.8-11 In patients presenting a glomerular filtration rate below 30ml/min, the use of cyclic GBCA should be well weighted against the potential risks and, if possible, avoided, while some linear GBCAs are contra-indicated.12 If the use of GBCAs is definitely contraindicated, then 3D SSFP sequences are a valuable alternative, obviating the need for CE MRA.
Administration of GBCAs in children below 2 years of age is currently off-label use and only cyclic GBCAs should be used.

3.3 Pacemaker, ICDs, epicardial pacemaker leads

CMR is generally contraindicated in patients after PM or ICD implantation. However, newer generations of implantable electrodes and generators are CMR conditional, performing CMR exams with these devices is safe and yields high quality images.13 Precautions and limitations of the implanted respective devices and electrodes have to be respected.14, 15 The presence of epicardial pacemaker leads is still a contraindication for CMR, because of the potential heating of the leads. In patients having undergone cardiac surgery, a chest X-ray is recommended after surgery and/or before the CMR examination to exclude the presence of residual epicardial pacemaker leads.

3.4 Pregnancy, breast-feeding

The risks and benefits of any imaging modality in pregnant patients have to be balanced. CMR with maximum field strength of 1.5T is considered safe regardless of gestational age when the benefit outweighs the risks, however and if possible, it should be postponed after the first trimester.16 CMR should be preferred over radiating imaging modalities.17 The use of GBCAs in pregnancy should be avoided as they cross the blood-placental barrier and their effects on the fetus are not known.16, 18 Only in clinical situations, which do not allow obtaining the required information without contrast agents, the use of GBCAs can be discussed and the lowest possible dose should be administered.
A very small percentage of GBCA, which is much lower than the maximal permitted intravenous dose for infants, is excreted to the breast milk after intravenous administration in breast-feeding patients.19 Nevertheless, it is recommended to interrupt breast-feeding for 24 hours after exposure to GBCA.

Myocardial stress perfusion examinations

A medical doctor with training in cardiopulmonary resuscitation has to be present during myocardial perfusion studies with adenosine, dipyridamole or dobutamine. Medication for cardiopulmonary life support and an external cardioverter-defibrillator have to be available outside the scanning room and be ready for use.

3.6 Medical devices and implants other than PM and ICDs

Respect the recommendations for the different implantable medical devices when performing CMR. Information about product safety is available on dedicated websites (e.g.
Exact description on how and where measurements have been taken is important for reproducibility and comparability of the measurements in the follow-up studies. The quality of images, i.e. non ECG-triggered CE MRA or ECG-triggered SSFP has to be specified. The aortic root should be visualized and measured with a gated sequence, such as SSFP, in order to avoid blurring due to the important vessel pulsatility.
Z-score calculators (validated for echocardiography):;

Level of measurements:

- Root: cusp to cusp, commissure to sinus, measured on SSFP or gradient echo, in systole in children, in diastole in adults31
- Sinotubular junction, ascending aorta at right pulmonary artery level, aortic arch, descending aorta at left pulmonary artery level, and at the level of the diaphragm, measured on CE MRA
Pulmonary arteries:
- MPA, LPA, RPA measured on CE MRA or 3D SSFP
Tabelle 2: Die fünf Fragen des Elder Abuse Suspicion Index (EASI) [6].
Frage 1Benötigen Sie Unterstützung von anderen ­Personen für eine der folgenden alltäglichen ­Verrichtungen: Baden, Ankleiden, Einkaufen, Rechnungen bezahlen, Mahlzeiten zubereiten?
Frage 2Hat Ihnen jemand je Esswaren, verordnete ­Medikamente, Ihre Brille, Ihr Hörgerät oder ­Medizinische Pflege vorenthalten oder Sie von Menschen, mit denen Sie sich gerne getroffen hätten, ferngehalten?
Frage 3Waren Sie je aufgebracht, weil jemand so mit ­Ihnen geredet hat oder umgegangen ist, dass Sie das beschämt hat oder Sie sich bedroht ­gefühlt haben?
Frage 4Hat jemand je versucht, Sie zu zwingen, gewisse Papiere zu unterschreiben oder Ihr Geld anders 
zu gebrauchen, als Sie es wollen?
Frage 5Hat jemand Sie je in Angst versetzt, Sie berührt auf eine Art, die Sie nicht wollten oder Ihnen ­körperliche Schmerzen zugefügt?

Worum geht es?

Bei Betagtenmisshandlung geht es um häusliche Gewalt gegen Ältere. Diese geschieht teils bewusst und absichtlich, teils unbewusst, gut gemeint aber überfordert bei der Hilfeleistung für Betagte. Sie umfasst gemäss dem in den letzten Jahren erreichten Konsens [1]:
– Körperliche Gewalt ( mit oder ohne sichtbare Verletzungen);
– Psychische Gewalt (verbale Aggressionen, Beschimpfungen, Beleidigungen, Drohungen mit Heimeinweisung oder im Stich lassen);
– Gewalt durch finanzielle Ausbeutung (z.B. Aneignung von Geld, Schmuck, Grundstücken oder Nötigung zur Änderung von Testament oder anderen Dokumenten);
– Sexuelle Gewalt (im Alter selten);
– Gewalt durch Vernachlässigung (Unterlassen von notwendiger Haushaltsunterstützung oder Pflegeleistungen, nicht abgeben von verordneten oder Überdosierung von beruhigenden Medikamenten, Vereiteln von Arztkonsultationen oder Spitexeinsätzen);
– Verletzung von Menschenrechten (z.B. durch Untersagen von Besuchen, Unterschlagen von Briefen, Einschliessen, Wegnahme von Ausweispapieren oder von Telefon/ Handy/ PC).

Epidemiologie der Betagtenmisshandlung

Es gibt keine repräsentativen Daten aus der Schweiz, aber aus sieben europäischen Ländern [2]: In sieben grossen Städten wurden je ca. 600 zu Hause lebende Betagte im Alter von 65–84 Jahren ohne Demenz zufällig ausgewählt und telefonisch über Erlebnisse von häuslicher Gewalt im vergangenen Jahr befragt. Durchschnittlich berichteten 22,6% über irgendeine Form von Gewalt (Range von 13,4% in Italien bis 29,0% in Deutschland und 30,1% in Schweden).
Am häufigsten war psychologische oder verbale Gewalt im Sinne von Bedrohung, Beschimpfung, Erniedrigung mit 19,8%, gefolgt von Vernachlässigung mit 4%, finanzielle Misshandlung 3,9% , physischer Gewalt 2,6% davon 0,7% mit Verletzung, und sexuelle Gewalt mit 1%. Auch in der Schweiz ist zu erwarten, dass sich jede fünfte ältere Person von jemandem aus ihrer Umgebung schlecht behandelt, in seiner Würde verletzt oder psychisch misshandelt vorkommt, und jede 25. betagte Person Opfer von Vernachlässigung , finanzieller oder körperlicher Gewalt wird. Die meisten dieser Misshandlungen bleiben unerkannt, und das Leiden  dauert über längere Zeit an.
Nicht berücksichtigt sind bei den Resultaten solcher repräsentativer Befragungen naturgemäss Misshandlung von sehr hochbetagten und von dementen Personen, die besonders häufig Opfer von Gewalt werden, weil ihre Betreuung oft die Angehörigen überfordert, sowie in Heimen lebende Betagte. Dort ist Misshandlung wegen der viel engeren sozialen Kontrolle seltener, auch wenn spektakuläre Einzelfälle aus Heimen oft grosse Medienaufmerksamkeit erlangen, im Unterschied zu solchen aus dem häuslichen Bereich.
The group of authors would like to thank the presidents of the working groups and societies who endorsed this manuscript for the support and help during the preparation of the manuscript:
- Dr. Judith Bouchardy, president of the working group “Adult Congenital Heart Disease (WATCH)” of the Swiss Society of Cardiology
- PD Dr. Hajo Müller, president of the working group “Echocardiography and Cardiac Imaging” of the Swiss Society of Cardiology
- PD Dr. Christian Balmer, president of the Swiss Society of Pediatric Cardiology
- Prof. Jens Bremerich, president of the “Ressort Cardiac Imaging” of the Swiss Society of Radiology” (also co-author of the document)
Funding / potential competing interests: No financial support and no other potential conflict of interest relevant to this article was reported.

«Plus d’utilité pour les patients et une meilleure ­rémunération par l’intégration»

Les effets indésirables (p. ex. prise en compte disproportionnée d’indicateurs «rentables», mesures biaisées) des modèles de rémunération basés sur les performances sont fréquents. Or les tarifs à la prestation et les forfaits par cas actuellement en vigueur ont également un impact défavorable (p. ex. augmentation du volume de prestations, doublons).
Les modèles de rémunération basés sur les performances doivent donc être conçus et ­appliqués de manière appropriée. Pour cela, il s’agit de mesurer l’ensemble du processus de prise en charge et de traitement et pas uniquement la prestation individuelle. La performance doit faire référence à l’ensemble du collectif de patients et pas à un cas particulier.
Albert Wettstein
Bickelstrasse 3a
CH-8942 Oberrieden
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3. NHTSA. “Drugs and human performance factsheet: Cannabis/ Marijuana”­job185drugs/cannabis.htm.
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