Echocardiography to the Rescue in Adult-Onset Partial Shone Complex

•Shone complex is a rare congenital disorder resulting in serial obstructive lesions. •Although often detected in childhood, partial Shone may present in adulthood. •Multimodality imaging may aid in the evaluation of different disease components. •Treatment requires multidisciplinary expertise and may include staged interventions.

The Interventional Imager: How Do We Train the Next Interventional Imagers?

With the increase in structural heart procedural volume, interventional imagers are required. Multiple imaging modalities exist to guide these procedures. With comprehensive understanding of pathology, anatomy, and procedures, an advanced imager plays an important role in the heart team. Imaging training is part of general cardiology fellowship. Current structures do not provide adequate procedural time to fill the role. Interested graduates pursue advanced training by either focusing on echocardiography and procedural imaging or multidetector computed tomography and cardiac magnetic resonance. This yields individuals with different expertise.

The Sword and the Crown: Echocardiography for the Detection of a Rare Combination of Congenital Heart Disease

•Unexplained right heart enlargement should always prompt evaluation for shunts. •Scimitar syndrome occurs when the right pulmonary veins drain into the IVC. •Coronary sinus dilation should prompt suspicion for PLSVC. •PLSVC can be diagnosed with a bubble study through left-sided IV.

National Core and Advanced Cardiac Imaging Curricula: A Framework From the Canadian Society of Thoracic Radiology Education Committee

RATIONALE

Well-defined curriculum with goals and objectives is an inherent part of every radiology residency program.

MATERIALS AND METHODS

Following a needs assessment, the Canadian Society of Thoracic Radiology education committee developed a cardiac imaging curriculum using a mixed method collaborative approach.

RESULTS

The Cardiovascular Imaging Curricula consist each of two separate yet complimentary granular parts: a Core Curriculum, aimed at residents in-training, with the main goal of building a strong foundational knowledge and an Advanced Curriculum, designed to build upon the core knowledge and guide a more in-depth fellowship subspecialty training.

CONCLUSION

The curricular frameworks aim to enhance the educational experience of trainees (residents and fellows) and provide an educational framework for clinical supervisors and residency and fellowship program directors.

SUMMARY STATEMENT

The Canadian Society of Thoracic Radiology (CSTR) championed the creation of Cardiovascular and Thoracic Imaging curricula encompassing clinical knowledge and technical, communication, and decision-making skills with the goal of providing direction to a strong foundational knowledge for residents and to guide specialty training for fellowship programs.

Proposed competencies for the performance of cardiovascular computed tomography in pediatric and adult congenital heart disease

Cardiovascular computed tomography (CCT) is rated appropriate by published guidelines for the initial evaluation and follow up of congenital heart disease (CHD) and is an essential modality in cardiac imaging programs for patients of all ages. However, no recommended core competencies exist to guide CCT in CHD imaging training pathways, curricula development, or establishment of a more formal educational platform. To fill this gap, a group of experienced congenital cardiac imagers, intentionally inclusive of adult and pediatric cardiologists and radiologists, was formed to propose core competencies fundamental to the expert-level performance of CCT in pediatric acquired and congenital heart disease and adult CHD. The 2020 SCCT Guideline for Training Cardiology and Radiology Trainees as Independent Practitioners (Level II) and Advanced Practitioners (Level III) in Cardiovascular Computed Tomography (1) for adult imaging were used as a framework to define pediatric and CHD-specific competencies. Established competencies will be immediately relevant for advanced cardiac imaging fellowships in both cardiology and radiology training pathways. Proposed future steps include radiology and cardiology society collaboration to establish provider certification levels, training case-volume recommendations, and continuing medical education (CME) requirements for expert-level performance of CCT in pediatric and adult CHD.

Contemporary cardiovascular computed tomography (CCT) training: Serial surveys of the international CCT community by the Fellow and Resident Leaders of the Society of Cardiovascular Computed Tomography (SCCT) Committee (FiRST) and SCCT Future Leaders Program (FLP)

BACKGROUND

As cardiovascular computed tomography (CCT) practice evolves, the demand for specialists continues to increase. However, CCT training remains variable globally with limited contemporaneous data to understand this heterogeneity. We sought to understand the role of CCT globally and the training available to underpin its use.

METHODS

We performed two consecutive surveys of cardiology and radiology physicians, two years apart, utilizing the Society of Cardiovascular Computed Tomography (SCCT) website, weblinks, social media platforms, and meeting handouts to maximize our response rate. We compared United States (US)-based vs. international responses to understand global similarities and differences in practice and training in the surveys.

RESULTS

235 respondents (37% trainees and 63% educators/non-trainees) initiated the first survey with 174 (74%) completing the core survey, with 205 providing their work location (114 US and 91 international). Eighty-four percent (92/110) of educator respondents stated a need for increased training opportunities to meet growing demand. Dedicated training fellowships are heterogenous, with limited access to structural heart imaging training, despite structural scanning being performed within institutions. The lack of a standardized curriculum was identified as the main obstacle to effective CCT learning, particularly in the US, with web-based learning platforms being the most popular option for improving access to CCT training. 148 trainees initiated the second survey with 107 (72%) completing the core components (51% North America, 49% international). Only 68% said they would be able to meet their required CCT education needs via their training program. Obstacles in obtaining CCT training again included a lack of a developed curriculum (51%), a lack of dedicated training time (35%), and a lack of local faculty expertise (31%). There was regional variability in access to CCT training, and, in contrast to the first survey, most (89%) felt 1:1 live review of cases with trained/expert reader was most useful for improving CCT training alongside formal curriculum/live lectures (72%).

CONCLUSIONS

There is a need to expand dedicated CCT training globally to meet the demand for complex CCT practice. Access to CCT education (didactic and 1:1 case-based teaching from expert faculty), implementation of recently published global training curricula, and increased teaching resources (web-based) as an adjunct to existing experiential learning opportunities, are all deemed necessary to address current educational shortfalls.

Appropriateness of cardiovascular computed tomography and magnetic resonance imaging in patients with conotruncal defects

BACKGROUND

To promote the rational use of cardiovascular imaging in patients with congenital heart disease, the American College of Cardiology developed Appropriate Use Criteria (AUC), but its clinical application and pre-release benchmarks have not been evaluated. We aimed to evaluate the appropriateness of indications for cardiovascular magnetic resonance (CMR) and cardiovascular computed tomography (CCT) in patients with conotruncal defects and to identify factors associated with maybe or rarely appropriate (M/R) indications.

METHODS

Twelve centers each contributed a median of 147 studies performed prior to AUC publication (01/2020) on patients with conotruncal defects. To incorporate patient characteristics and center-level effects, a hierarchical generalized linear mixed model was used.

RESULTS

Of the 1753 studies (80% CMR, and 20% CCT), 16% were rated M/R. Center M/R ranged from 4 to 39%. Infants accounted for 8.4% of studies. In multivariable analyses, patient- and study-level factors associated with M/R rating included: age <1 year (OR 1.90 [1.15-3.13]), truncus arteriosus (vs. tetralogy of Fallot, OR 2.55 [1.5-4.35]), and CCT (vs. CMR, OR 2.67 [1.87-3.83]). None of the provider- or center-level factors reached statistical significance in the multivariable model.

CONCLUSIONS

Most CMRs and CCTs ordered for the follow-up care of patients with conotruncal defects were rated appropriate. However, there was significant center-level variation in appropriateness ratings. Younger age, CCT, and truncus arteriosus were independently associated with higher odds of M/R rating. These findings could inform future quality improvement initiatives and further exploration of factors resulting in center-level variation.

Recommendations for cardiovascular magnetic resonance and computed tomography in congenital heart disease: a consensus paper from the CMR/CCT working group of the Italian Society of Pediatric Cardiology (SICP) and the Italian College of Cardiac Radiology endorsed by the Italian Society of Medical and Interventional Radiology (SIRM) Part I

Cardiovascular magnetic resonance (CMR) and computed tomography (CCT) are advanced imaging modalities that recently revolutionized the conventional diagnostic approach to congenital heart diseases (CHD), supporting echocardiography and often replacing cardiac catheterization. Nevertheless, correct execution and interpretation require in-depth knowledge of all technical and clinical aspects of CHD, a careful assessment of risks and benefits before each exam, proper imaging protocols to maximize diagnostic information, minimizing harm. This position paper, written by experts from the Working Group of the Italian Society of Pediatric Cardiology and from the Italian College of Cardiac Radiology of the Italian Society of Medical and Interventional Radiology, is intended as a practical guide for applying CCT and CMR in children and adults with CHD, wishing to support Radiologists, Pediatricians, Cardiologists and Cardiac Surgeons in the multimodality diagnostic approach to these patients. The first part provides a review of the most relevant literature in the field, describes each modality's advantage and drawback, making considerations on the main applications, image quality, and safety issues. The second part focuses on clinical indications and appropriateness criteria for CMR and CCT, considering the level of CHD complexity, the clinical and logistic setting and the operator expertise.

Artificial intelligence in cardiovascular CT: Current status and future implications

Artificial intelligence (AI) refers to the use of computational techniques to mimic human thought processes and learning capacity. The past decade has seen a rapid proliferation of AI developments for cardiovascular computed tomography (CT). These algorithms aim to increase efficiency, objectivity, and performance in clinical tasks such as image quality improvement, structure segmentation, quantitative measurements, and outcome prediction. By doing so, AI has the potential to streamline clinical workflow, increase interpretative speed and accuracy, and inform subsequent clinical pathways. This review covers state-of-the-art AI techniques in cardiovascular CT and the future role of AI as a clinical support tool.

Highlights of the 16th annual scientific meeting of the society of cardiovascular computed tomography

The 16th Society of Cardiovascular Computed Tomography (SCCT) annual scientific meeting welcomed 781 digital attendees from 55 countries. The program included 27 sessions across three simultaneously streaming channels, 11 exhibitors, 153 poster presentations, and 32 ​hours of on demand videos. The main themes of the meeting included coronary artery disease, valvular heart disease, structural heart disease, and advanced analytics including machine learning. This article summaries the main themes of the meeting and some of the key presentations, which will shape the future of cardiovascular computed tomography in clinical practice.

Predictors of pacemaker implantation after TAVI in a registry including self, balloon and mechanical expandable valves

The need for permanent pacemaker implantation (PPMI) is a burdensome complication of transcatheter aortic valve implantation (TAVI). The aim of our study was to evaluate different anatomical, clinical, electrocardiographic, and procedural variables associated with the development of conduction abnormalities after TAVI across the entire device spectrum. Single-center prospective cohort of consecutive patients who underwent TAVI since March 2017. Final cohort was studied to detect areas of calcium within aortic valve characterized by leaflet sector and region. Membranous septum (MS) length was assessed throughout a modified coronal view. Device selection and positioning were performed according to the operator criteria. Device selection and positioning were performed according to the operator criteria. From the 273 patients included, 57 underwent PPMI (20.8%). Univariate analysis determined right bundle branch block (RBBB), QRS duration, MS length and calcium within LVOT of non-coronary cuspid as independent predictors. After multivariable logistic regression, both RBBB (OR 6.138; 95% CI 1.23-30.73, P = 0.027) and MS length (OR 0.259; 95% CI 0.164-0.399, P < 0.005) emerged as statistically significant. As a model, they could predict PPMI in 88.7%, independently of which valve used. Youden index analysis yielded 7.69 mm as the optimal cut-off with a negative and positive predictive value of 94.7 and 71.9%, respectively. In our experience, both RBBB pattern and short membranous septum (< 8 mm) were strongly and independently associated with new permanent pacemaker implantation, regardless of the device type. Our findings suggest that this simple evolved measure of MS length may guide device selection and implantation technique and facilitate early discharge.

Myocardial Involvement in Rheumatic Disorders

PURPOSE OF REVIEW

Autoimmune rheumatic diseases (ARDs) affect 8% of the population and approximately 78% of patients are women. Myocardial disease in ARDs is the endpoint of various pathophysiologic mechanisms including atherosclerosis, valvular disease, systemic, myocardial, and/or vascular inflammation, as well as myocardial ischemia and replacement/diffuse fibrosis.

RECENT FINDINGS

The increased risk of CVD in ARDs leads to excess comorbidity not fully explained by traditional cardiovascular risk factors. It seems that the chronic inflammatory status typically seen in ARDs, promotes both the development of myocardial inflammation/fibrosis and the acceleration of atherosclerosis. CMR (cardio-vascular magnetic resonance) is the ideal imaging modality for the evaluation of cardiac involvement in patients with ARDs, as it can simultaneously assess cardiac function and characterize myocardial tissues with regard to oedema and fibrosis. Due to its high spatial resolution, CMR is capable of identifying various disease entities such as myocardial oedema /inflammation, subendocardial vasculitis and myocardial fibrosis, that are often missed by other imaging modalities, notably at an early stage of development. Although generally accepted guidelines about the application of CMR in ARDs have not yet been formulated, according to our experience and the available published literature, we recommend CMR in ARD patientS with new-onset heart failure (HF), arrhythmia, for treatment evaluation/change or if there is any mismatch between patient symptoms and routine non-invasive evaluation.

Balloon-expandable valve geometry after transcatheter aortic valve replacement in low-risk patients with bicuspid versus tricuspid aortic stenosis

BACKGROUND

Prospective bicuspid low-risk transcatheter aortic valve replacement (TAVR) registries' data demonstrated encouraging short-term results. Detailed data on transcatheter heart valve (THV) geometry after deployment using contemporary devices are lacking. This study sought to examine valve geometry after TAVR in patients with bicuspid aortic stenosis (AS).

METHODS

The study population was patients from the LRT (Low Risk TAVR) trial who underwent TAVR using the SAPIEN 3 THV for bicuspid and tricuspid AS. THV geometry measured on 30-day computed tomography (CT) included valve height, angle, depth, and eccentricity. Additionally, THV hemodynamics and outcomes post-TAVR were compared among patients with bicuspid and tricuspid AS.

RESULTS

A total of 107 patients from the LRT trial using the SAPIEN 3 THV were included in our analysis. On 30-day CT, the valve height ratio (1.07 vs. 1.07; p = 0.348), depths (right [5.6 mm vs. 6.2 mm; p = 0.223], left [5.3 mm vs. 4.4 mm; p = 0.082] and non [4.8 mm vs. 4.5 mm; p = 0.589] coronary cusps), eccentricities (1.08 vs. 1.07; p = 0.9550), and angles (except the right [3.9 degrees vs. 6.3 degrees; p = 0.003] and left [3.6 degrees vs. 6.0 degrees; p = 0.007]) were similar between bicuspid and tricuspid patients. Hemodynamics, stroke, and mortality were similar at 1 year.

CONCLUSION

Despite challenging bicuspid anatomy of the aortic valve, our comprehensive CT analysis supports similar THV geometry between patients with bicuspid and tricuspid AS undergoing TAVR using the SAPIEN 3 THV in low-risk patients. This translated to excellent short-term clinical outcomes and THV hemodynamics in both aortic valve morphologies.

TRIAL REGISTRY

NCT02628899, https://clinicaltrials.gov/ct2/show/NCT02628899.

Cardiac imaging procedures and the COVID-19 pandemic: recommendations of the European Society of Cardiovascular Radiology (ESCR)

The severe acute respiratory syndrome coronavirus 2019 (SARS-CoV-2) pandemic currently constitutes a significant burden on worldwide health care systems, with important implications on many levels, including radiology departments. Given the established fundamental role of cardiovascular imaging in modern healthcare, and the specific value of cardiopulmonary radiology in COVID-19 patients, departmental organisation and imaging programs need to be restructured during the pandemic in order to provide access to modern cardiovascular services to both infected and non-infected patients while ensuring safety for healthcare professionals. The uninterrupted availability of cardiovascular radiology services remains, particularly during the current pandemic outbreak, crucial for the initial evaluation and further follow-up of patients with suspected or known cardiovascular diseases in order to avoid unnecessary complications. Suspected or established COVID-19 patients may also have concomitant cardiovascular symptoms and require further imaging investigations. This statement by the European Society of Cardiovascular Radiology (ESCR) provides information on measures for safety of healthcare professionals and recommendations for cardiovascular imaging during the pandemic in both non-infected and COVID-19 patients.

High-quality low-dose cardiovascular computed tomography (CCT) in pediatric patients using a 64-slice scanner

Background Cardiovascular computed tomography (CCT) technology is rapidly advancing allowing to perform good quality examinations with a radiation dose as low as 1.2 mSv. However, latest generation scanners are not available in all centers. Purpose To estimate radiation dose and image quality in pediatric CCT using a standard 64-slice scanner. Material and Methods A total of 100 patients aged 6.9 ± 5.4 years (mean ± standard deviation) who underwent a 64-slice CCT scan using 80, 100, or 120 kVp, were retrospectively evaluated. Radiation effective dose was calculated on the basis of the dose length product. Two independent readers assessed the image quality through signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and a qualitative score (3 = very good, 2 = good, 1 = poor). Non-parametric tests were used. Results Fifty-five exams were not electrocardiographically (ECG) triggered, 20 had a prospective ECG triggering, and 25 had retrospective ECG triggering. The median effective dose was 1.3 mSv (interquartile range [IQR] = 0.8-2.7 mSv). Median SNR was 30.6 (IQR = 23.4-33.6) at 120 kVp, 29.4 (IQR = 23.7-34.8) at 100 kVp, and 24.7 (IQR = 19.4-34.3) at 80 kVp. Median CNR was 21.0 (IQR = 14.8-24.4), 19.1 (IQR = 15.6-23.9), and 25.3 (IQR = 19.4-33.4), respectively. Image quality was very good, good, and poor in 56, 39, and 5 patients, respectively. No significant differences were found among voltage groups for SNR ( P = 0.486), CNR ( P = 0.336), and subjective image quality ( P = 0.296). The inter-observer reproducibility was almost perfect (κ = 0.880). Conclusion High-quality pediatric CCT can be performed using a 64-slice scanner, with a radiation effective dose close to 2 mSv in about 50% of the cases.

Normal values of regional left ventricular myocardial thickness, mass and distribution-assessed by 320-detector computed tomography angiography in the Copenhagen General Population Study

Left ventricular (LV) hypertrophy is associated with cardiovascular complications and the geometry is important for prognosis. In some cardiovascular diseases, myocardial hypertrophy or dilation occurs regionally without modifying the global size of the heart. It is therefore relevant to determine regional normal reference values of the left ventricle. The aim of this study was to derive reference values of regional LV myocardial thickness (LVMT) and mass (LVMM) from a healthy study group of the general population using cardiac computed tomography angiography (CCTA). We wanted to introduce LV myocardial distribution (LVMD) as a measure of regional variation of the LVMT. Moreover, we wanted to determine whether these parameters varied between men and women. We studied 568 (181 men; 32%) adults, free of cardiovascular disease and risk factors, who underwent 320-detector CCTA. Mean age was 55 (range 40-84) years. Regional LVMT and LVMM were measured, according to the American Heart Association's 17 segment model, using semi-automatic software. Mean LVMT were 6.6 mm for men and 5.4 mm for women (p < 0.001). The normal LV was thickest in the basal septum (segment 3; men = 8.3 mm; women = 7.2 mm) and thinnest in the mid-ventricular anterior wall (segment 7; men = 5.6 mm; women = 4.5 mm) for both men and women. However, the regional LVMD differed between men and women, with the LV being most heterogenic in women. The normal human LV is morphologically heterogenic, and showed same overall pattern but different regional distribution for men and women. This study introduces LVMD and provides gender specific reference values for regional LVMT, LVMM, and LVMD.

Cardiovascular magnetic resonance as a reliable alternative to cardiovascular computed tomography and transesophageal echocardiography for aortic annulus valve sizing

To assess the accuracy and reproducibly of cardiovascular magnetic resonance (CMR) in the measurement of the aortic annulus and in process of valve sizing as compared to intra-operative sizing, cardiovascular computed tomography (CCT) and transesophageal echocardiography (TEE). Retrospective study on 42 patients who underwent aortic valve replacement from September 2010 to September 2015, with available records of pre surgery annulus assessment by CMR, CCT and TEE and of peri-operative assessment. In CCT and CMR, the annular plane was considered a virtual ring formed by the lowest hinge points of the valvular attachments to the aorta. In TEE the annulus was measured at the base of leaflet insertion in the mid-esophageal long-axis view using the X-plane technique. Two double-blinded operators performed the assessments for each imaging technique. Intra-operative evaluation was performed using Hegar dilators. Continuous variables were studied with within-subject ANOVA, Bland-Altman (BA) plots, Wilcoxon's and Friedman's tests; trends were explored with scatter plots. Categorical variables were studied with Fisher's exact test. The intra- and inter-operator reliability was satisfying. There were no significant differences between the annulus dimensions measured by CMR and either one of the three references. Valve sizing for CoreValve by CMR had the same good agreement with CCT and TEE, with a 78 % match rate; for SAPIEN XT the agreement was slightly better (82 %) for CCT than for TEE (66 %). MR performs well when compared to the surgical reference of intra-operative sizing and stands up to the level of the most used imaging references (CCT and TEE).

“How many times must a man look up before he can really see the sky?” Rheumatic cardiovascular disease in the era of multimodality imaging

Cardiovascular involvement in rheumatic diseases (RD) is the result of various pathophysiologic mechanisms including inflammation, accelerated atherosclerosis, myocardial ischemia, due to micro- or macro-vascular lesions and fibrosis. Noninvasive cardiovascular imaging, including echocardiography, nuclear techniques, cardiovascular computed tomography and cardiovascular magnetic resonance, represents the main diagnostic tool for early, non-invasive diagnosis of heart disease in RD. However, in the era of multimodality imaging and financial crisis there is an imperative need for rational use of imaging techniques in order to obtain the maximum benefit at the lowest possible cost for the health insurance system. The oligo-asymptomatic cardiovascular presentation and the high cardiovascular mortality of RD necessitate a reliable and reproducible diagnostic approach to catch early cardiovascular involvement. Echocardiography remains the routine cornerstone of cardiovascular evaluation. However, a normal echocardiogram can not always exclude cardiac involvement and/or identify heart disease acuity and pathophysiology. Therefore, cardiovascular magnetic resonance is a necessary adjunct complementary to echocardiography, especially in new onset heart failure and when there are conflicting data from clinical, electrocardiographic and echocardiographic evaluation of RD patients.