Letter to the Editor A segmental approach to criss-cross heart by cardiac MRI Massimiliano Cantinotti ⁎ ,1 , Aaron Bell 1 , Sanjeet Hegde 1 , Reza Razavi 1 Division of Imaging Sciences, 5th floor Thomas Guy House, GuyTs Hospital, London SE1 9RT, United Kingdom Received 8 December 2006; accepted 3 January 2007 Available online 2 April 2007 Abstract Criss-cross heart is a rare congenital heart defect. The unusual arrangement of the atrio-ventricular connection, and associated abnormalities make it a challenging condition to image. We describe 3 cases of criss-cross heart who underwent cardiac MRI in order to comprehensively evaluate the anatomy and plan surgical management. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Criss-cross heart; MRI; Congenital heart disease Criss-cross heart is a rare and complex form of congenital heart disease characterised by a twisted atrio-ventricular connection as a result of rotation of the ventricular mass along its long axis [1]. It may present with all kinds of atrio- ventricular and ventriculo-arterial connections and is fre- quently seen with a superior–inferior relationship of the ventricular mass [2–4]. We have used cardiac MRI (CMR) to image three patients with criss-cross atrio-ventricular connections. Imaging was performed under general anaesthesia with a 1.5 T Philips Gyroscan Intera. Informed consent was obtained for all subjects. CMR imaging included isotropic 3D volume images of the heart and great vessels, 2 dimensional cine images in selected imaging planes, phase contrast flow images of great vessels and 3D Gadolinium MR angiogram (MRA). Image analysis was performed on View-Forum (Release 4.1), Philips Medical Systems, Best, the Netherlands. In all three patients the atria were normally positioned (atrial situs solitus), atrio-ventricular connections were concordant and a ventricular septal defect (VSD) was present. Case 1: A 4-year-old girl with discordant ventriculo- arterial (VA) connections and associated atrial septal defect (ASD), VSD and pulmonary stenosis. The cardiac apex was located on the left and the right ventricle (RV) was positioned antero-superior to the left. Her previous surgery had been a Right Modified Blalock Taussig Shunt and a superior cavo-pulmonary connection. She was being assessed for suitability for completion of cavo-pulmonary connection. Case 2: A 3-year-old boy with a double outlet right ventricle and associated ASD, VSD, pulmonary valve and branch pulmonary artery stenosis with aorto-pulmonary collaterals. His cardiac apex was on the right and the ventricular relationship was normal. He had been palliated with a superior cavo-pulmonary shunt and was awaiting completion of cavo-pulmonary connection. Case 3: A 6-month-old girl with associated VSD and coarctation of the aorta. The cardiac apex was on the left and RV was orientated superior to the left. She had previous coarctation repair and pulmonary artery banding and was being assessed to determine her future surgical strategy (Figs. 1 and 2). International Journal of Cardiology 118 (2007) e103 – e105 www.elsevier.com/locate/ijcard ⁎ Corresponding author. Division of Imaging Sciences, 5-th floor Thomas Guy House, Kings College London, London, SE19RT, United Kingdom. Tel.: +44 20 7188 5441; fax: +44 20 71885442. E-mail addresses: cantinotti@hotmail.it, cantinotti@hotmail.com, cantinotti@ifc.cnr.it (M. Cantinotti). 1 Tel.: +44 20 71885441. 0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2007.01.063