ROLE OF CT-SCAN IN ASSESSMENT OF CONGENITAL HEART DISEASES. Dr.Sherif Sabet Fellow Pediatric Cardiologist Imaging Unit PSCC

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1 ROLE OF CT-SCAN IN ASSESSMENT OF CONGENITAL HEART DISEASES Dr.Sherif Sabet Fellow Pediatric Cardiologist Imaging Unit PSCC

2 Ultrasonic echocardiography (UCG) is effective, noninvasive, and the most commonly used examination method for Congenital Heart Disease (CHD) (Curtis and Stuart, 2005).

3 Diagnostic Cardiac Catheterization (DCC) is performed as an invasive method if ECHO fails to provide a confident evaluation of the cardiac lesions. However, non-invasive cardiac imaging using CTA or MRI has evolved rapidly (Ley etal., 2007).

5 Echocardiography

6 Echocardiography is a routine non invasive examination for diagnosing CHD. It provides real-time, dynamic views & multiple cross section 2D imaging with lack of radiation.

7 Echocardiography cannot display the extracardiac vessels In addition to being highly operator dependent (Klewer et al., 2002). Tsai IC, Chen MC, Jan SL, et al. Neonatal cardiac multidetector row CT: why and how we do it. Pediatr Radiol 2008; 38:

8 Diagnostic Cardiac Catheterization

9 Diagnostic Cardiac Catheterization (DCC) has long been the gold standard for evaluating cardiac anatomy and function. The only method that can be used to determine pulmonary vascular pressure and oxygen saturation. (Lee et al., 2006)

10 Limitations Of DCC

11 DCC is an invasive method, it can induce complications such as vascular injury, thrombogenesis and arrhythmia High doses of ionizing radiation Requires a larger volume of intravascular contrast material The complexity of the operation restricts body positions, and the overlap of the heart and large vessels

12 Cardiac MRI

13 Cardiac MRI is a non-invasive test using powerful magnet fields and radio waves rather than X-rays to provide remarkably clear and detailed images of the heart and extra cardiac structures.

14 MRI has several limitations compared with CT: Image artifacts from implanted metal, such stents & coils Contraindication in imaging of patients with pacemakers Higher cost ; limited availability ; MRI also takes longer time than CT Increased Need for general anesthesia in younger children Taylor AM. Cardiac imaging: MR or CT? Which to use when. Pediatr Radiol 2008; 38[suppl 3]:S433 S438

15 MRI is limited in the evaluation of the airways and lungs, structures that CT depicts well. Tsai IC, Chen MC, Jan SL, et al. Neonatal cardiac multidetector row CT: why and how we do it. Pediatr Radiol 2008; 38:

16 Cardiac CT Angiography

17 The cardiac CTA is a non invasive & credible examination with fast scanning and clear visualization of cardiovascular deformities.

18 Advantages

19 The combination of 2D & 3D images demonstrates extra cardiac structures and CA anomalies. Requires lesser intravascular contrast material. Rapid imaging requires less patient sedation. Less artifacts. Good for airways and lungs imaging.

20 Clinical Indications

21 CT can be used when ECHO is limited and other imaging modalities are not available or contraindicated.

22 CT can be used in the pre- & post operative evaluation of CHD patients whose condition suddenly deteriorates Bean MJ, Pannu H, Fishman EK. Three-dimensional computed tomographic imaging of complex congenital cardiovascular abnormalities. J Comput Assist Tomogr 2005; 29:

23 CT can be considered the first-line imaging technique for some clinical indications Evaluation of Suspected vascular ring or sling.

24 Evaluation of Suspected aortopulmonary collateral arteries in patients with severe right ventricular outflow tract obstruction.

25 Evaluation of Individuals with implanted pacemakers and metal surgical hardware who cannot undergo MRI Non cooperative / claustrophobia

26 The Limitations of CTA

27 Limitations of CTA 1- Radiation

28 Chest X-ray provides about 0.02 msv or the equivalent of 2.4 days of natural background radiation. Radiation dose associated with a typical CT scan is comparable to the annual dose received from natural sources of radiation. Coles DR, Smail MA, Negus IS, et al. Comparison of radiation doses from multislice computed tomography coronary angiography and conventional diagnostic angiography. J Am Coll Cardiol May 2;47(9):

29 Rumberger JA, Brundage BH, Rader DJ, et al. Electron beam computed tomographic coronary calcium scanning: a review and guidelines for use in asymptomatic persons. Mayo Clin Proc. 1999; 74:

30 Children are : More sensitive to radiation than adults. Have a longer life span from the point of the scan, there is greater potential for radiation induced malignancies.

31 Radiation Dose Directly proportional to: Kilo voltage Tube Current Scan time Slice thickness and number Field of view

32 Lower radiation exposure

33 Optimize CT settings Reduce tube current and voltage Increase table speed (mm/sec) Limit number of scans increase slice thickness Eliminate inappropriate referrals for CT!!

34 Our own radiation exposure range for pediatric CTA in PSCC is from 0.28 msv to 0.7 msv

35 Limitations of CTA 2- Can not provide information regarding: Hemodynamics (flow and volume) Blood oxygen content

36 3- Cardiac CT is limited in the evaluation of intracardiac anomalies in non ECG gated studies

37 Techniques and Parameters of Pediatric CTA

38 CONTRAST Contrast mandatory in 100% of cases! It is important to be familiar with a patient s anatomy and surgical history before contrast administration. Goo HW, Park IS, Ko JK, et al. CT of congenital heart disease: normal anatomy and typical pathologic conditions. RadioGraphics 2003; 23:S147 S165

40 Imaging of Some Congenital Cardiovascular Disease

41 Infra cardiac

42 TAPVD (Infra-cardiac type)

57 1 from LSCA 2,3,4 from DAo

58 1 and 3 supply RPA

60 LPA

62 THE ROLE OF CARDIAC CT IS INCREASING!! Challenges: Optimize contrast enhancement Lower radiation dose

Cardiology Fellowship Manual. Goals & Objectives -Cardiac Imaging- 1 Page

Cardiology Fellowship Manual. Goals & Objectives -Cardiac Imaging- 1 Page Cardiology Fellowship Manual Goals & Objectives -Cardiac Imaging- 1 Page 2015-2016 UNIV. OF NEBRASKA CHILDREN S HOSPITAL & MEDICAL CENTER DIVISION OF CARDIOLOGY FELLOWSHIP PROGRAM CARDIAC IMAGING ROTATION