Two for One: Combined Heart-Liver MRI for Monitoring Individuals with Fontan Circulation

Background: Those with Fontan palliated single ventricle heart disease have hemodynamic alterations that contribute to a range of long-term complications including systolic ventricular dysfunction as well as liver congestion, fibrosis, and an increased risk of hepatocellular carcinoma (HCC)1. As a result, many centers recommend routine surveillance with cardiovascular magnetic resonance imaging (CMR) and liver MRI2,3. At our center, these are performed as separate exams—a 75-min CMR with extracellular contrast agent and a 90-min liver MRI with hepatobiliary specific contrast agent and elastography—scheduled on different days due to scan duration and contrast incompatibility. This approach increases the time and logistical burden for patients and families, highlighting the need for more efficient, patient-centered surveillance strategies. To address this, we developed a combined heart-liver MRI protocol that allows comprehensive surveillance during a single 75-min session. Here, we report our initial experience implementing this protocol.

Methods: In this IRB-approved, single-center retrospective study, 39 patients underwent a combined heart-liver MRI between May 2024 and May 2025. The new combined protocol (Table 1) uses a single contrast agent (gadoxetate disodium; Eovist), interleaves cardiac and liver sequences to maximize efficiency, and reduced 2D phase contrast acquisitions from 12 to 8. For each patient, we recorded the total scanner time for the combined protocol and compared it to available prior CMR and/or liver MRI exam times.

Results: Demographic and exam data are reported in Table 2. The median age of patients was 21 years. Thirty-three of 39 patients (85%) completed the combined protocol; there was no significant difference in age between those who were able to complete the protocol and those unable (p=0.65). Reasons for not completing the combined study included pain (1), anxiety (1), lack of cooperation (1), and hardware artifact (2). The median scan time for the combined protocol was 70 min compared to 127 min required for separate CMR and liver MRI exams. Since implementing the combined protocol, 75% of all CMRs and 36% of all liver MRIs for Fontan-related surveillance have been performed as combined studies (Figure).

Conclusion: The combined heart-liver MRI protocol for Fontan patients reduces total scan time while delivering comprehensive surveillance data. Adoption at our institution has been high, with most Fontan surveillance CMRs now performed as combined heart-liver studies, reflecting a strong preference for a streamlined, patient-centered approach.

Combined heart-liver protocol

Combined heart-liver protocol
Sequence/Step	Est. Time	Indication
Survey	0.5
Coronal single shot fast spin echo liver	3	Liver & spleen anatomy, presence of ascites
MR Elastography	5	Liver stiffness
Axial 3D T1 GRE pre-contrast	0.5	Liver anatomy
Quantitative Dixon liver	0.5	Quantitative assessment of liver fat (PDFF) and iron (T2*)
Inject gadoxetate disodium
Axial T1 GRE arterial	0.3	Liver parenchymal enhancement and identification of focal lesions
Ax T1 GRE portal venous	0.3
Ax T1 GRE late venous	0.3
3D whole heart	8	Cardiovascular anatomy
Axial T2 FS liver	5	Liver anatomy, parenchymal and lesion evaluation
Axial DWI liver	5	Focal lesion detection and characterization
Cardiac cines	12	Assessment of cardiac morphology and function
AX STACK CINE
2CH LV CINE
SA LOC CINE
4CH CINE STACK
SA STK CINE
3CH CINE
COR FONTAN CINE
Axial 3D GRE stack of stars (radial) hepatobiliary phase	4	Evaluation of liver parenchyma and focal lesion characterization
Cor 3D GRE liver	1
2D PCs	15	Quantitative flow assessment
QF ASC AO 200
QF AOV 200
QF AVV 100
QF RPA 80
QF LPA 80
QF SVC 100
QF IVC 100
QF DESC AO 200
ESTIMATED TOTAL TIME	60
ACTUAL AVERAGE TIME	72

Completed Studies Characteristics

Completed Studies Characteristics (n=33)
	Median
Age (years)	21
Combined Heart-Liver scan time (min)	70
Total Scan Time for previous stand-alone abdomen and cardiac MR (min)	127
Abdominal alone scan time (min)	62
Cardiac alone scan time (min)	68
Total number of completed scans	33

Total number of liver and cardiac MR exams performed in individuals with Fontan circulation at CCHMC since 2021 separated by individual exams (blue) vs. combined (orange)