Visualization of a Small Ventricular Septal Defect at First-pass Contrast-enhanced Cardiac Magnetic Resonance Imaging
Here we present a case of a 12-year-old male (height 144 cm, weight 32 kg), born at term by spontaneous delivery, who had been previously diagnosed with a muscular VSD and an atrial septal defect (ASD). The ASD was closed by surgical intervention. In 2006, non-compaction of left ventricle (LV) posterior wall was suspected at echocardiography. In 2010, an echocardiographic examination was performed at our institution. The report was as follows: Situs solitus, normal atrio-ventricular and ventricular-arterial connections, no ASDs; small muscular apical VSD of 3 mm in diameter [] and patchy appearance of the posterior wall of the LV. The patient was recommended a cardiac MRI exam.\nCardiac MR was performed using a 1.5-T scanner (Sonata, Siemens, Erlangen, Germany), with a 4-element phased-array cardiac coil. Cine steady-state free precession (SSFP) sequences were acquired on long-axis two-chamber, four-chamber, and short-axis views to cover the whole LV. A retrospective electrocardiogram-gating was used. A turbo-gradient-echo first-pass perfusion with echoplanar readouts sequence was acquired for three long-axis four-chamber slices. Contrast material (0.1 mmol/kg of gadoterate meglumine for a total of 7 ml), followed by 20 ml of saline solution were intravenously injected, through a 22 G plastic needle in an antecubital vein of the left arm, at a rate 2 ml/min. Cine true-fast imaging with steady-state precession images were segmented semiautomatically (Syngo-Argus, version VE32B, Siemens Medical Solutions, Erlangen, Germany) to obtain ejection fraction (EF), end-diastolic volume (EDV), normalized to body surface area (EDV index [EDVI]), and end-systolic volume index (ESVI) of the LV and right ventricle (RV).\nThe cine SSFP sequences showed a hypertrabeculation of the mid-lateral and inferior wall and of the apical septum with a ratio between normal and hypertrabeculated myocardium of about two[] [ and ]. No septal defect was initially detected on cine evaluation. During the first-pass perfusion, a jet of highly concentrated contrast material was clearly visible from the apical VSD throughout the RV [ and ]. We calculated following LV and RV volumes and EF: EDVI 91 ml/m2 and ESVI 29 ml/m2 and EF 68% for LV, EDVI 49 ml/m2, ESVI 24 ml/m2 and EF 52% for RV. The following diagnosis was reported: Apical VSD and hypertrabeculation of the mid-lateral and inferior wall and of the apical septum.