Review New Directives in Cardiac Imaging: Imaging the Adult With Congenital Heart Disease Jonathan D. Windram, MBChB, a Samuel C. Siu, MS, MD, b Rachel M. Wald, MD, a,c and Candice K. Silversides, MS, MD a a University of Toronto, Division of Cardiology, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada b University of Western Ontario, Division of Cardiology, London, Ontario, Canada c University of Toronto, Division of Cardiology, Medical Imaging Department, University Health Network, Toronto, Ontario, Canada ABSTRACT Advances in pediatric surgical and interventional techniques and medical care over the past 50 years have revolutionized the care of children with congenital heart disease. Survival to adulthood is now expected and, as such, there is a growing population of adults which is exceeding the pediatric population with congenital heart disease. Noninvasive cardiac imaging with modalities such as echocardiog- raphy, computed tomography, and cardiac magnetic resonance imaging are integral to the care of adults with congenital heart disease. These modalities are used for diagnosis, surveillance for complications late after surgery and catheter-based interventions, and in decision-making for medical, interventional, and surgical therapies. In this review we will discuss noninvasive imaging modalities used to assess congenital cardiac lesions, imaging strategies for select congenital lesions, and comment on the future of cardiac imaging in congenital heart disease. R  ESUM  E Les progrès en matière de chirurgie p ediatrique, de techniques inter- ventionnelles et de soins m edicaux au cours des 50 dernières ann ees ont r evolutionn e les soins aux enfants ayant une cardiopathie con- g enitale. On s’attend maintenant à une survie jusqu’àl’âge adulte et, à ce titre, la population adulte est sup erieure à la population p ediatrique ayant une cardiopathie cong enitale. L’imagerie cardiaque non effrac- tive qui utilise des modalit es comme l’ echocardiographie, la tomo- densitom etrie et l’imagerie cardiaque par r esonance magn etique fait partie int egrante des soins aux adultes ayant une cardiopathie con- g enitale. Ces modalit es sont utilis ees pour le diagnostic, la surveillance des complications tardives de la chirurgie et les interventions par cath eter, ainsi que pour la prise de d ecision quant aux traitements m edicaux, interventionnels et chirurgicaux. Dans cette revue, nous discuterons des modalit es d’imagerie non effractive utilis ees pour  evaluer les l esions cardiaques cong enitales et des strat egies d’ima- gerie de certaines l esions cong enitales, et  emettrons des commen- taires sur l’avenir de l’imagerie cardiaque dans l’ evaluation de la cardiopathie cong enitale. Advances in pediatric surgical and interventional techniques and medical care have improved survival for children born with congenital heart disease. As a consequence, there are a growing number of adults with congenital heart disease. Cardiac imaging plays an integral role in the management of adults with congenital heart disease aiding with diagnoses, surveillance for complications late after surgeries and catheter- based interventions, and in the decision-making for inter- ventional, surgical, and medical therapies. Knowledge and understanding of congenital cardiac anatomy, terminology, pathophysiology, and surgical and/or interventional procedures are fundamental in adult congenital heart disease (ACHD) imaging. When performing and interpreting complex congenital imaging studies, a segmental approach to the cardiac anatomy is used to ensure that important pathology is not missed. 1 Standard views might be inadequate and atypical views might be required. Comple- mentary multimodality imaging is often needed for compre- hensive assessment of these patients because of the complex nature of the cardiac anatomy and pathophysiology. Longi- tudinal imaging data are also very important when following adults with congenital cardiac lesions. Cardiac imaging should be performed at centres with technicians and readers with expertise in ACHD. 2-5 Even adults with simple congenital cardiac lesions might benefit from an initial assessment at a specialized centre because simple lesions have associated defects that can be overlooked. Received for publication November 14, 2012. Accepted April 17, 2013. Corresponding author: Dr Jonathan D. Windram, University of Alberta, Division of Cardiology, Mazankowski Alberta Heart Institute, 2C2 WMC, 8440 e 112 St, Edmonton, Alberta T6G 2B7, Canada. Tel.: þ1-780-407- 3177; fax: þ1-780-407-6452. E-mail: jonathan.windram@albertahealthservices.ca See page 838 for disclosure information. 0828-282X/$ - see front matter Ó 2013 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cjca.2013.04.020 Canadian Journal of Cardiology 29 (2013) 830e840