Imaging insights from the bifurcated Y-graft Fontan procedure

Abstract

Results From August, 2010 to July, 2015, 45 children (median age 3.6 years, range 1.5 18.9 years) have undergone a Y-graft Fontan. In all 45 patients, echocardiography was unable to visualize the Y-arm connections to the branch PA’s. Thirty-nine patients underwent CMR a median of 9 days after Fontan (range 4-295 days), and 6 patients with pacemakers underwent CTA. Early in the experience, time resolved contrast enhanced magnetic resonance angiogram (CEMRA) provided the best spatial resolution for baffle evaluation (Figure 1a). In late 2013, our CMR protocol changed to include a blood pool Gadolinium contrast agent, Gadofosveset Trisodium. Subsequently, postcontrast, 3D, respiratory navigated, inversion recovery gradient echo imaging (3D IR GRE) provided superior spatial resolution for the final 19 children (Figure 1b). In one patient, thrombosis in the baffle was found. In 40 patients, some degree of stenosis was found in a Fontan baffle or branch PA, though most were mild (n = 27). Among those with moderate or severe stenosis, most occurred in the central PA, between the insertion of the bidirectional Glenn (BDG) and a Y-arm (n = 7). Phase contrast imaging and the time resolved CEMRA provided insights into Fontan hemodynamics. In 14 patients, inferior systemic venous return was affected by the BDG position and angulation, with competitive flow in either the left or right Y-arm resulting in asymmetric inferior systemic venous return to the branch PA’s (Figure 2). This finding was more pronounced in patients with central PA stenosis.