Magnetic resonance elastography is useful to determine the severity of liver fibrosis according to liver biopsy in post-fontan patients
Objective The reliability of various modalities for assessing and monitoring Fontan-associated liver disease compared to liver biopsy remains an intriguing subject of inquiry. Our objective was to assess the efficacy of multiple modalities in comparison to liver histology for evaluating liver fibros...
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| Veröffentlicht in: | The international journal of cardiovascular imaging 2025-01, Vol.41 (1), p.15-25 |
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| creator | Sethasathien, Saviga Leemasawat, Krit Sittiwangkul, Rekwan Makonkawkeyoon, Krit Leerapun, Apinya Kongkarnka, Sarawut Inmutto, Nakarin Silvilairat, Suchaya |
| description | Objective
The reliability of various modalities for assessing and monitoring Fontan-associated liver disease compared to liver biopsy remains an intriguing subject of inquiry. Our objective was to assess the efficacy of multiple modalities in comparison to liver histology for evaluating liver fibrosis in post-Fontan patients.
Methods
We conducted a cross-sectional study involving Fontan patients without known liver disease. Eligible patients underwent cardiac and hepatic evaluations, including ultrasound liver elastography, magnetic resonance elastography (MRE) of the liver, computerized tomography (CT) scan of the upper abdomen, echocardiography, cardiac catheterization, and liver biopsy. The severity of liver fibrosis was categorized using the METAVIR score derived from liver biopsy results: F0/F1 indicated no or mild fibrosis, F2 indicated significant fibrosis, F3 indicated advanced fibrosis and F4 indicated cirrhosis.
Results
A total of 38 patients (mean age 21 ± 6.5 years, 52.6% female) were included in the cross-sectional study, with a mean time elapsed since the Fontan operation of 13 years. Parameters obtained from echocardiography, ultrasound liver elastography, and CT scan of the upper abdomen did not exhibit significant differences among the groups. Notably, liver biopsy revealed advanced cirrhosis in 23 out of 38 patients and none were diagnosed with hepatocellular carcinoma. Multivariate logistic regression analysis demonstrated that the factor significantly associated with significant liver fibrosis or cirrhosis in post-Fontan patients was liver stiffness with MRE > 4.4 kPa [OR 13.5 (95% CI 1.2-152.2)].
Conclusions
Our findings suggest that post-Fontan patients with liver stiffness of MRE > 4.4 kPa should undergo further investigation. These results contribute to understanding the liver fibrosis assessment in post-Fontan patients and highlight the importance of MRE in predicting significant liver disease.
Graphical Abstract |
| doi_str_mv | 10.1007/s10554-024-03276-8 |
| format | Article |
| fullrecord | <record><control><sourceid>proquest_cross</sourceid><recordid>TN_cdi_proquest_miscellaneous_3128321018</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>3128321018</sourcerecordid><originalsourceid>FETCH-LOGICAL-c256t-32e348c524ea3b33a8854a9e16be9e38e6b384f1a9eb10590359d3bba3621723</originalsourceid><addsrcrecordid>eNp9kcuOFSEQhonROBd9AReGxI2bVqCabnppJt6SMW5mT6BP9RkmfaClaJPzBPPacuzxEhcuCH-or36gfsZeSPFGCtG_JSm0bhuh6gLVd415xM6l6XVjQKrHf-kzdkF0J4TsYRiesjMYtJRS9efs_ovbRyxh5BkpRRdH5Dg7Kmmf3XJ75IH4SjitMy-J77BgPoSIvNwiJ_yOOZQjTxOfQ9V8Cj4nqi1uHFPehbg_dW01H9JC1S_yJVFpphSLq9qVgLHQM_ZkcjPh84f9kt18eH9z9am5_vrx89W762ZUuisNKITWjFq16MADOGN06waUnccBwWDnwbSTrEe-TmcQoIcdeO-gU7JXcMleb7ZLTt9WpGIPgUacZxcxrWTrrAwoKaSp6Kt_0Lu05lgfVynddUOvhKiU2qixfpwyTnbJ4eDy0UphTynZLSVbU7I_U7In65cP1qs_4O53y69YKgAbQLUU95j_3P0f2x9jup71</addsrcrecordid><sourcetype>Aggregation Database</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>3156697200</pqid></control><display><type>article</type><title>Magnetic resonance elastography is useful to determine the severity of liver fibrosis according to liver biopsy in post-fontan patients</title><source>MEDLINE</source><source>SpringerLink Journals - AutoHoldings</source><creator>Sethasathien, Saviga ; Leemasawat, Krit ; Sittiwangkul, Rekwan ; Makonkawkeyoon, Krit ; Leerapun, Apinya ; Kongkarnka, Sarawut ; Inmutto, Nakarin ; Silvilairat, Suchaya</creator><creatorcontrib>Sethasathien, Saviga ; Leemasawat, Krit ; Sittiwangkul, Rekwan ; Makonkawkeyoon, Krit ; Leerapun, Apinya ; Kongkarnka, Sarawut ; Inmutto, Nakarin ; Silvilairat, Suchaya</creatorcontrib><description>Objective
The reliability of various modalities for assessing and monitoring Fontan-associated liver disease compared to liver biopsy remains an intriguing subject of inquiry. Our objective was to assess the efficacy of multiple modalities in comparison to liver histology for evaluating liver fibrosis in post-Fontan patients.
Methods
We conducted a cross-sectional study involving Fontan patients without known liver disease. Eligible patients underwent cardiac and hepatic evaluations, including ultrasound liver elastography, magnetic resonance elastography (MRE) of the liver, computerized tomography (CT) scan of the upper abdomen, echocardiography, cardiac catheterization, and liver biopsy. The severity of liver fibrosis was categorized using the METAVIR score derived from liver biopsy results: F0/F1 indicated no or mild fibrosis, F2 indicated significant fibrosis, F3 indicated advanced fibrosis and F4 indicated cirrhosis.
Results
A total of 38 patients (mean age 21 ± 6.5 years, 52.6% female) were included in the cross-sectional study, with a mean time elapsed since the Fontan operation of 13 years. Parameters obtained from echocardiography, ultrasound liver elastography, and CT scan of the upper abdomen did not exhibit significant differences among the groups. Notably, liver biopsy revealed advanced cirrhosis in 23 out of 38 patients and none were diagnosed with hepatocellular carcinoma. Multivariate logistic regression analysis demonstrated that the factor significantly associated with significant liver fibrosis or cirrhosis in post-Fontan patients was liver stiffness with MRE > 4.4 kPa [OR 13.5 (95% CI 1.2-152.2)].
Conclusions
Our findings suggest that post-Fontan patients with liver stiffness of MRE > 4.4 kPa should undergo further investigation. These results contribute to understanding the liver fibrosis assessment in post-Fontan patients and highlight the importance of MRE in predicting significant liver disease.
Graphical Abstract</description><identifier>ISSN: 1875-8312</identifier><identifier>ISSN: 1569-5794</identifier><identifier>EISSN: 1875-8312</identifier><identifier>EISSN: 1573-0743</identifier><identifier>DOI: 10.1007/s10554-024-03276-8</identifier><identifier>PMID: 39511127</identifier><language>eng</language><publisher>Dordrecht: Springer Netherlands</publisher><subject>Abdomen ; Adolescent ; Adult ; Biopsy ; Cardiac Imaging ; Cardiology ; Cirrhosis ; Computed tomography ; Coronary artery disease ; Cross-Sectional Studies ; Echocardiography ; Elasticity Imaging Techniques ; Female ; Fibrosis ; Fontan Procedure - adverse effects ; Heart Defects, Congenital - complications ; Heart Defects, Congenital - diagnostic imaging ; Heart Defects, Congenital - surgery ; Heart diseases ; Hepatocellular carcinoma ; Histology ; Humans ; Imaging ; Liver ; Liver - diagnostic imaging ; Liver - pathology ; Liver cancer ; Liver cirrhosis ; Liver Cirrhosis - diagnostic imaging ; Liver Cirrhosis - pathology ; Liver diseases ; Magnetic resonance ; Magnetic Resonance Imaging ; Male ; Medicine ; Medicine & Public Health ; Original Paper ; Predictive Value of Tests ; Radiology ; Regression analysis ; Reproducibility of Results ; Risk Factors ; Severity of Illness Index ; Stiffness ; Time Factors ; Tomography, X-Ray Computed ; Treatment Outcome ; Ultrasonic imaging ; Ultrasound ; Young Adult</subject><ispartof>The international journal of cardiovascular imaging, 2025-01, Vol.41 (1), p.15-25</ispartof><rights>The Author(s), under exclusive licence to Springer Nature B.V. 2024 Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.</rights><rights>2024. The Author(s), under exclusive licence to Springer Nature B.V.</rights><rights>Copyright Springer Nature B.V. Jan 2025</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><cites>FETCH-LOGICAL-c256t-32e348c524ea3b33a8854a9e16be9e38e6b384f1a9eb10590359d3bba3621723</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://link.springer.com/content/pdf/10.1007/s10554-024-03276-8$$EPDF$$P50$$Gspringer$$H</linktopdf><linktohtml>$$Uhttps://link.springer.com/10.1007/s10554-024-03276-8$$EHTML$$P50$$Gspringer$$H</linktohtml><link.rule.ids>314,776,780,27901,27902,41464,42533,51294</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/39511127$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Sethasathien, Saviga</creatorcontrib><creatorcontrib>Leemasawat, Krit</creatorcontrib><creatorcontrib>Sittiwangkul, Rekwan</creatorcontrib><creatorcontrib>Makonkawkeyoon, Krit</creatorcontrib><creatorcontrib>Leerapun, Apinya</creatorcontrib><creatorcontrib>Kongkarnka, Sarawut</creatorcontrib><creatorcontrib>Inmutto, Nakarin</creatorcontrib><creatorcontrib>Silvilairat, Suchaya</creatorcontrib><title>Magnetic resonance elastography is useful to determine the severity of liver fibrosis according to liver biopsy in post-fontan patients</title><title>The international journal of cardiovascular imaging</title><addtitle>Int J Cardiovasc Imaging</addtitle><addtitle>Int J Cardiovasc Imaging</addtitle><description>Objective
The reliability of various modalities for assessing and monitoring Fontan-associated liver disease compared to liver biopsy remains an intriguing subject of inquiry. Our objective was to assess the efficacy of multiple modalities in comparison to liver histology for evaluating liver fibrosis in post-Fontan patients.
Methods
We conducted a cross-sectional study involving Fontan patients without known liver disease. Eligible patients underwent cardiac and hepatic evaluations, including ultrasound liver elastography, magnetic resonance elastography (MRE) of the liver, computerized tomography (CT) scan of the upper abdomen, echocardiography, cardiac catheterization, and liver biopsy. The severity of liver fibrosis was categorized using the METAVIR score derived from liver biopsy results: F0/F1 indicated no or mild fibrosis, F2 indicated significant fibrosis, F3 indicated advanced fibrosis and F4 indicated cirrhosis.
Results
A total of 38 patients (mean age 21 ± 6.5 years, 52.6% female) were included in the cross-sectional study, with a mean time elapsed since the Fontan operation of 13 years. Parameters obtained from echocardiography, ultrasound liver elastography, and CT scan of the upper abdomen did not exhibit significant differences among the groups. Notably, liver biopsy revealed advanced cirrhosis in 23 out of 38 patients and none were diagnosed with hepatocellular carcinoma. Multivariate logistic regression analysis demonstrated that the factor significantly associated with significant liver fibrosis or cirrhosis in post-Fontan patients was liver stiffness with MRE > 4.4 kPa [OR 13.5 (95% CI 1.2-152.2)].
Conclusions
Our findings suggest that post-Fontan patients with liver stiffness of MRE > 4.4 kPa should undergo further investigation. These results contribute to understanding the liver fibrosis assessment in post-Fontan patients and highlight the importance of MRE in predicting significant liver disease.
Graphical Abstract</description><subject>Abdomen</subject><subject>Adolescent</subject><subject>Adult</subject><subject>Biopsy</subject><subject>Cardiac Imaging</subject><subject>Cardiology</subject><subject>Cirrhosis</subject><subject>Computed tomography</subject><subject>Coronary artery disease</subject><subject>Cross-Sectional Studies</subject><subject>Echocardiography</subject><subject>Elasticity Imaging Techniques</subject><subject>Female</subject><subject>Fibrosis</subject><subject>Fontan Procedure - adverse effects</subject><subject>Heart Defects, Congenital - complications</subject><subject>Heart Defects, Congenital - diagnostic imaging</subject><subject>Heart Defects, Congenital - surgery</subject><subject>Heart diseases</subject><subject>Hepatocellular carcinoma</subject><subject>Histology</subject><subject>Humans</subject><subject>Imaging</subject><subject>Liver</subject><subject>Liver - diagnostic imaging</subject><subject>Liver - pathology</subject><subject>Liver cancer</subject><subject>Liver cirrhosis</subject><subject>Liver Cirrhosis - diagnostic imaging</subject><subject>Liver Cirrhosis - pathology</subject><subject>Liver diseases</subject><subject>Magnetic resonance</subject><subject>Magnetic Resonance Imaging</subject><subject>Male</subject><subject>Medicine</subject><subject>Medicine & Public Health</subject><subject>Original Paper</subject><subject>Predictive Value of Tests</subject><subject>Radiology</subject><subject>Regression analysis</subject><subject>Reproducibility of Results</subject><subject>Risk Factors</subject><subject>Severity of Illness Index</subject><subject>Stiffness</subject><subject>Time Factors</subject><subject>Tomography, X-Ray Computed</subject><subject>Treatment Outcome</subject><subject>Ultrasonic imaging</subject><subject>Ultrasound</subject><subject>Young Adult</subject><issn>1875-8312</issn><issn>1569-5794</issn><issn>1875-8312</issn><issn>1573-0743</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2025</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNp9kcuOFSEQhonROBd9AReGxI2bVqCabnppJt6SMW5mT6BP9RkmfaClaJPzBPPacuzxEhcuCH-or36gfsZeSPFGCtG_JSm0bhuh6gLVd415xM6l6XVjQKrHf-kzdkF0J4TsYRiesjMYtJRS9efs_ovbRyxh5BkpRRdH5Dg7Kmmf3XJ75IH4SjitMy-J77BgPoSIvNwiJ_yOOZQjTxOfQ9V8Cj4nqi1uHFPehbg_dW01H9JC1S_yJVFpphSLq9qVgLHQM_ZkcjPh84f9kt18eH9z9am5_vrx89W762ZUuisNKITWjFq16MADOGN06waUnccBwWDnwbSTrEe-TmcQoIcdeO-gU7JXcMleb7ZLTt9WpGIPgUacZxcxrWTrrAwoKaSp6Kt_0Lu05lgfVynddUOvhKiU2qixfpwyTnbJ4eDy0UphTynZLSVbU7I_U7In65cP1qs_4O53y69YKgAbQLUU95j_3P0f2x9jup71</recordid><startdate>20250101</startdate><enddate>20250101</enddate><creator>Sethasathien, Saviga</creator><creator>Leemasawat, Krit</creator><creator>Sittiwangkul, Rekwan</creator><creator>Makonkawkeyoon, Krit</creator><creator>Leerapun, Apinya</creator><creator>Kongkarnka, Sarawut</creator><creator>Inmutto, Nakarin</creator><creator>Silvilairat, Suchaya</creator><general>Springer Netherlands</general><general>Springer Nature B.V</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>8FD</scope><scope>FR3</scope><scope>K9.</scope><scope>M7Z</scope><scope>P64</scope><scope>7X8</scope></search><sort><creationdate>20250101</creationdate><title>Magnetic resonance elastography is useful to determine the severity of liver fibrosis according to liver biopsy in post-fontan patients</title><author>Sethasathien, Saviga ; Leemasawat, Krit ; Sittiwangkul, Rekwan ; Makonkawkeyoon, Krit ; Leerapun, Apinya ; Kongkarnka, Sarawut ; Inmutto, Nakarin ; Silvilairat, Suchaya</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c256t-32e348c524ea3b33a8854a9e16be9e38e6b384f1a9eb10590359d3bba3621723</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2025</creationdate><topic>Abdomen</topic><topic>Adolescent</topic><topic>Adult</topic><topic>Biopsy</topic><topic>Cardiac Imaging</topic><topic>Cardiology</topic><topic>Cirrhosis</topic><topic>Computed tomography</topic><topic>Coronary artery disease</topic><topic>Cross-Sectional Studies</topic><topic>Echocardiography</topic><topic>Elasticity Imaging Techniques</topic><topic>Female</topic><topic>Fibrosis</topic><topic>Fontan Procedure - adverse effects</topic><topic>Heart Defects, Congenital - complications</topic><topic>Heart Defects, Congenital - diagnostic imaging</topic><topic>Heart Defects, Congenital - surgery</topic><topic>Heart diseases</topic><topic>Hepatocellular carcinoma</topic><topic>Histology</topic><topic>Humans</topic><topic>Imaging</topic><topic>Liver</topic><topic>Liver - diagnostic imaging</topic><topic>Liver - pathology</topic><topic>Liver cancer</topic><topic>Liver cirrhosis</topic><topic>Liver Cirrhosis - diagnostic imaging</topic><topic>Liver Cirrhosis - pathology</topic><topic>Liver diseases</topic><topic>Magnetic resonance</topic><topic>Magnetic Resonance Imaging</topic><topic>Male</topic><topic>Medicine</topic><topic>Medicine & Public Health</topic><topic>Original Paper</topic><topic>Predictive Value of Tests</topic><topic>Radiology</topic><topic>Regression analysis</topic><topic>Reproducibility of Results</topic><topic>Risk Factors</topic><topic>Severity of Illness Index</topic><topic>Stiffness</topic><topic>Time Factors</topic><topic>Tomography, X-Ray Computed</topic><topic>Treatment Outcome</topic><topic>Ultrasonic imaging</topic><topic>Ultrasound</topic><topic>Young Adult</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Sethasathien, Saviga</creatorcontrib><creatorcontrib>Leemasawat, Krit</creatorcontrib><creatorcontrib>Sittiwangkul, Rekwan</creatorcontrib><creatorcontrib>Makonkawkeyoon, Krit</creatorcontrib><creatorcontrib>Leerapun, Apinya</creatorcontrib><creatorcontrib>Kongkarnka, Sarawut</creatorcontrib><creatorcontrib>Inmutto, Nakarin</creatorcontrib><creatorcontrib>Silvilairat, Suchaya</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>Technology Research Database</collection><collection>Engineering Research Database</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Biochemistry Abstracts 1</collection><collection>Biotechnology and BioEngineering Abstracts</collection><collection>MEDLINE - Academic</collection><jtitle>The international journal of cardiovascular imaging</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Sethasathien, Saviga</au><au>Leemasawat, Krit</au><au>Sittiwangkul, Rekwan</au><au>Makonkawkeyoon, Krit</au><au>Leerapun, Apinya</au><au>Kongkarnka, Sarawut</au><au>Inmutto, Nakarin</au><au>Silvilairat, Suchaya</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Magnetic resonance elastography is useful to determine the severity of liver fibrosis according to liver biopsy in post-fontan patients</atitle><jtitle>The international journal of cardiovascular imaging</jtitle><stitle>Int J Cardiovasc Imaging</stitle><addtitle>Int J Cardiovasc Imaging</addtitle><date>2025-01-01</date><risdate>2025</risdate><volume>41</volume><issue>1</issue><spage>15</spage><epage>25</epage><pages>15-25</pages><issn>1875-8312</issn><issn>1569-5794</issn><eissn>1875-8312</eissn><eissn>1573-0743</eissn><abstract>Objective
The reliability of various modalities for assessing and monitoring Fontan-associated liver disease compared to liver biopsy remains an intriguing subject of inquiry. Our objective was to assess the efficacy of multiple modalities in comparison to liver histology for evaluating liver fibrosis in post-Fontan patients.
Methods
We conducted a cross-sectional study involving Fontan patients without known liver disease. Eligible patients underwent cardiac and hepatic evaluations, including ultrasound liver elastography, magnetic resonance elastography (MRE) of the liver, computerized tomography (CT) scan of the upper abdomen, echocardiography, cardiac catheterization, and liver biopsy. The severity of liver fibrosis was categorized using the METAVIR score derived from liver biopsy results: F0/F1 indicated no or mild fibrosis, F2 indicated significant fibrosis, F3 indicated advanced fibrosis and F4 indicated cirrhosis.
Results
A total of 38 patients (mean age 21 ± 6.5 years, 52.6% female) were included in the cross-sectional study, with a mean time elapsed since the Fontan operation of 13 years. Parameters obtained from echocardiography, ultrasound liver elastography, and CT scan of the upper abdomen did not exhibit significant differences among the groups. Notably, liver biopsy revealed advanced cirrhosis in 23 out of 38 patients and none were diagnosed with hepatocellular carcinoma. Multivariate logistic regression analysis demonstrated that the factor significantly associated with significant liver fibrosis or cirrhosis in post-Fontan patients was liver stiffness with MRE > 4.4 kPa [OR 13.5 (95% CI 1.2-152.2)].
Conclusions
Our findings suggest that post-Fontan patients with liver stiffness of MRE > 4.4 kPa should undergo further investigation. These results contribute to understanding the liver fibrosis assessment in post-Fontan patients and highlight the importance of MRE in predicting significant liver disease.
Graphical Abstract</abstract><cop>Dordrecht</cop><pub>Springer Netherlands</pub><pmid>39511127</pmid><doi>10.1007/s10554-024-03276-8</doi><tpages>11</tpages></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 1875-8312 |
| ispartof | The international journal of cardiovascular imaging, 2025-01, Vol.41 (1), p.15-25 |
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| subjects | Abdomen Adolescent Adult Biopsy Cardiac Imaging Cardiology Cirrhosis Computed tomography Coronary artery disease Cross-Sectional Studies Echocardiography Elasticity Imaging Techniques Female Fibrosis Fontan Procedure - adverse effects Heart Defects, Congenital - complications Heart Defects, Congenital - diagnostic imaging Heart Defects, Congenital - surgery Heart diseases Hepatocellular carcinoma Histology Humans Imaging Liver Liver - diagnostic imaging Liver - pathology Liver cancer Liver cirrhosis Liver Cirrhosis - diagnostic imaging Liver Cirrhosis - pathology Liver diseases Magnetic resonance Magnetic Resonance Imaging Male Medicine Medicine & Public Health Original Paper Predictive Value of Tests Radiology Regression analysis Reproducibility of Results Risk Factors Severity of Illness Index Stiffness Time Factors Tomography, X-Ray Computed Treatment Outcome Ultrasonic imaging Ultrasound Young Adult |
| title | Magnetic resonance elastography is useful to determine the severity of liver fibrosis according to liver biopsy in post-fontan patients |
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