Cinematic Rendering Technique in Adult
Congenital Heart Disease
Victor Fiorentino,* Harold Goerne,*,† and Prabhakar Rajiah, MBBS, MD, FRCR, FSCMRz
Introduction
A dult congenital heart disease (ACHD) is a common refer-
ral in the cardiac imaging practice. Thanks to advances
in surgical techniques and peri-operative care, more than
95% of patients with congenital heart disease (CHD) now
survive into adulthood, with most of them living till 60 years
of age and beyond.1-3 ACHD patients require life-long clini-
cal follow-up, with imaging performed to screen and evaluate
postsurgical/interventional complications. In these patients,
comprehensive delineation of the anatomy is essential to
identify abnormalities, determine further management and
provide a roadmap for future surgeries/interventions. Echo-
cardiography is the first-line imaging modality used in
ACHD. It provides functional information on the left ventri-
cle; however, evaluation of the right ventricle is limited in
adults due to acoustic window restrictions. 3D echocardio-
graphic technique is available for anatomical evaluation, but
it has a limited field of view (FOV) for visualizing extra-car-
diac structures and cannot visualize air-filled structures. In
addition, echocardiography is highly operator dependent
and has an even more restricted FOV in patients with obesity
and airway diseases.4
Computed tomography (CT) and magnetic resonance
imaging (MRI) can provide more comprehensive anatomical
information than echocardiogram, without the FOV restric-
tions of echocardiogram. For CT and MRI, multiple 2D post-
processing techniques are available to facilitate the evaluation
of anatomy, which is often complex and challenging in
patients with ACHD, particularly following multiple surger-
ies and interventions. Multiplanar reconstruction (MPR) gen-
erates images in any desired plane. High-quality MPR images
*Department of Radiology, Western National Medical Center IMSS, Guada-
lajara, Jalisco, Mexico.
y
Department of Radiology, Imaging and diagnostic Center CID, Guadalajara,
Jalisco, Mexico.
z
Department of Radiology, Cardiovascular Imaging, Mayo Clinic, Rochester,
MN.
Address reprint requests to Prabhakar Rajiah, MBBS, MD, FRCR, FSCMR,
Department of Radiology, Cardiovascular Imaging, Mayo Clinic, 200 1st
Street SW, Rochester, MN, 559905. E-mail: radpr73@gmail.com
https://doi.org/10.1053/j.ro.2020.06.013
0037-198X/© 2020 Elsevier Inc. All rights reserved.
can be generated in CT due to its high isotropic spatial reso-
lution. Dedicated cardiac views, including long- and short-
axis can be generated.5-8 If cine images are reconstructed,
dynamic imaging (4D) is achieved. Curved multiplanar
reconstruction is a technique in which vascular structures are
stretched in a single plane. These images can be rotated 360°
to provide a bird’s eye view of the vessel. Using centerline
analysis, the vessel can then be tracked along an automated
or semiautomated central axis, to provide cross-sectional
views. Double oblique reconstruction is obtained from 2
orthogonal views and is used for accurate and reproducible
measurement of vascular structures. Maximum intensity pro-
jection is a technique in which the high-density voxels are
preferentially displayed along any plane of interest at any
slice thickness. This is useful for the evaluation of small ves-
sels and high attenuation structures such as contrast, calcifi-
cations and grafts.
3D Reconstruction Techniques
3D reconstructions provide a more comprehensive visualiza-
tion of the anatomy, including the relationship between adja-
cent structures. They provide a global view of the volumetric
data in a single plane, which is difficult to appreciate on 2D
images. In shaded surface display (SSD), the surface of an
anatomical region is displayed by selecting the superficial val-
ues of a volume that are closest to the computer display. Sub-
sequently artificially-processed light beams are used to
generate the final appearance of a shaded surface. This tech-
nique is however limited to displaying only 10% of the infor-
mation cube and its accuracy depends on the correct
selection of the anatomical points.5,6,9 Volume rendering
(VR) is the current 3D-visualization standard for CT or MRI
data. In VR, the entire volume of data is processed to gener-
ate a 3D image that is projected on a 2D display and can be
manipulated in real-time to display anatomical information
from any perspective.10 VR uses a local lighting model and
the ray casting principle, in which for each pixel, 1 virtual
light ray is cast through the line of voxels. There are 3 steps
in VR, namely formation, classification and image projection
241