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Prise en charge des congénitauxScanner cardiaque pédiatrique:
consensus d’experts 2019
Karine Warin Fresse MD1
Isorni MA, MD2, Dacher JN, MDPHD3, Pontana F, MDPHD4, Gorincour G MDPHD5, MD, Raimondi F, MD6
1Imagerie cardiovasculaire, Fédération des cardiopathies congénitales, CHU Nantes2Cardiologie, CCML, Paris, 3Radiologie, CHU Rouen, 4Radiologie CHU Lille; 5Radiologie CHU Marseilles,
6Cardiopédiatrie Necker-enfants malades, Paris
Introduction
• Cardiac Computed Tomography Angiography (CTA):
– has progressively replaced cardiac catheterization
– is now often used as a diagnostic tool complementary to echocardiography.
• Challenge:
–breath-holding issues,
–uncontrolled movement
–high heart rate,
–complex anatomy and small structures
• Indications
• Patient preparation
• CTA techniques
• Dose reduction
• Post processing
• Structured report
Indications
• Coronary arteries
• Systemic vessels– Aortic coarctation
– Complex arch anomalies
– Supra valvular aortic stenosis
– Aorto-pulmonary window
– Pulmonary arteries
• Pulmonary venous anomalies
• Transposition of great arteries
• Intracardiac anatomy : complex congenital heart disease– for surgical strategy
– 3D modeling from CT data may be reconstructed and eventually printed to help in planning surgical strategy Raimondi F, Warin Fresse K. Arch Cardiovasc Dis. 2016;109(2):150-7
Han BK et al. J Cardiovasc Comput Tomogr. 2015; 9(6):493-513Han BK et al. J Cardiovasc Comput Tomogr. 2015; 9(6):475-492
Coronary Artery Imaging
Han BK et al. J Cardiovasc Comput Tomogr. 2015; 9(6):475-492
11 month 9 kgTGV
136 bpmDLP 25 mGy.cm / 0.6 msv
14 month 10 kgTGV
155 bpmDLP 31.4 mGy.cm : 0.8msv
Coronary arteries
ARCAPA
Co-arctation
• At the time of the diagnosis as a complement TTE
• During follow up:
–After surgical correction
–Before catheter intervention
• Restenosis,
• Residual stenosis,
• Aneurysm or pseudoaneurysm
–Aortic arch hypoplasia
15 yoProspective acquisition
80 cc Visipaque 320 40 cc saline flush
HR: 93 bpm. No prémédication. PDL : 56 mGy.cm
Complex arch anomalies
Double Aortic Arch
Pulmonary venous anomalies
6 month, 6 kgatrial septal defect
VPARHR 110 bpm
DLP 16.1 mGy.cm
Transposition of Great Arteries
Complex Congenital heart diseaseCriss Cross Heart
Patient preparation
• Good injection site (peripheral vein of arm, foot or head) (1,5cc/s power injector )
• ECG electrode on the chest outside the exam zone to avoid artefact• comfortably installed in specially designed bed with blanket and bands to
avoid movement and keep warm• > 5-6 yo:
• Exam and breath should be explained • Apnea
• < 6 yo:• BB < 3-6 mois: baby bottle• 6 mois- 6 ans: light sedation
Booij R et al. J Cardiovasc Comput Tomogr. 2016; 10(6):13-21
CTA technique
• Abandoned technique:
–Non-ECG- synchronized helical scan
–Retrospectively ECG- gated scan
• 2 CT scan acquisition depending on:
–Prospectively ECG triggered sequential acquisition
–One shot acquisition.
ECG triggered sequential acquisition
• Step-and-shoot acquisition
• Any heart rate condition and even in free breathing
• Biphasic injection of iodinated contrast followed by a saline flush (1cc/kg) using a power injector :
– 270-300 mgI/L < 40 kg,
– 320-350 mgI/L > 40kg
• Beta-blockers could be used not to decrease the heart rate but to stabilize it.
Prospective Acquisition
One shot acquisition
allows to acquire the whole heart within one single heart beat
Heart rate (bpm)any heart rate
ECG Synchronisation/acquisition Prospective/ Axial Cardiac
Weight (kg)any Weight until 50 Kg
kV max70-80
mA Smart mA 150-450
Exposure Window0,25-0,5 s
Collimation16 cm
Target phase 40-50% if HR > 65 bpm 75% si < 65 bpm
Rotation time (ms) 0.28 sec
Lenght (mm)120-140 mm
Field of Vue (SFOV) small
Slice Thickness (mm)0.625 mm
Reconstruction algorythm ASIR 40%
Motion correction algorythm Freeze if HR variation
Heart rate (bpm) 30 to 180
ECG Synchronisation/acquisitionProspective target auto /one shot acquisition / one
beat
Weight (kg) any Weight until 50 Kg
kVp 80kV
mA mA Modulation (SUREExposure)
Exposure Window 350-400 ms
Collimation (mm) 0.5x240 to 0.5x320 (adapted to the heart)
Target phase Auto target phase (75% if HR70 bpm
Rotation time (ms) 0,275 s
Lenght (mm) 120-160 mm
Field of Vue (SFOV) 240 mm
Slice Thickness and interval (mm) 0.5 - 0.25
Reconstruction algorythm iterative
Motion correction algorythm PhaseExact (best phase)
REVO CT General Electric ACQUILLION ONE GENESIS Canon Medical system
Dose reduction
• First step :
–to choose the more adapted scanning protocol for the patient
–and his clinical characteristics
• Second step:
–Reconstruction algorithms (specific /vendors)
–Iterative reconstructions
Dose
E (mSv) = DLP (mGy.cm) x fDLP (mSv/mGy.cm)
Dose
• Pas de NRD (Niveau Référence Diagnostic) en cardiopédiatrie• NRD scanner pédiatrique
0,78 mSv 1,17 mSv 1,82 mSv
www.nrd.irsn.fr
CHU Nantes
Nouveau nés (n=12)
1 -12 mois (n=22)
13-60 mois(n=22)
61-120 mois (n=23)
>120 mois(n=18)
DLP moyenne (mGy.cm) 15,55 21, 45 29,91 40,08 55,52
Dose (mSv) 0,6 0,56 0,54 0,52 0,72
NRD 0,78 0,78 1,17 1,17 1,82
< 10 KG (35) 10-20 KG (23) 20-30 kg (12) >30 kg (27)
DLP moyenne (mGy.cm) 20,69 35,56 36,74 55,02
NRD (mGy.cm)
Acquisition prospective Acquisition rétrospective
270mgI/L 320mgI/L 320mgI/L
Liu Z et al. Int J Clin Pract 2016
N = 90
• Diagnostic accuracy:
– Extra-cardiaque: 100% in 3 groups
– Intra-cardiaque: A-C: 100% for A, B: 96%
• Low dose, Low concentrationLiu Z et al. Int J Clin Pract 2016
Bouchra HG et al. Eur Radiol 2015
Post-processing
• Best cardiac phase
• Motion correction
• Windowing
• Multiplanar recontructions
• Maximum intensity projection
• Volume Rendering
Best cardiac phase 72%
3 years old22 cc VISIPAQUE 270, 10 cc saline flush
145 bpm.PDL : 37.9 mGy.cm
Best cardiac phase 41%
3 years old22 cc VISIPAQUE 270, 10 cc saline flush
145 bpm.PDL : 37.9 mGy.cm
Best cardiac phase 51%
3 years old22 cc VISIPAQUE 270, 10 cc saline flush
145 bpm.PDL : 37.9 mGy.cm
Best cardiac phase 61%
3 years old22 cc VISIPAQUE 270, 10 cc saline flush
145 bpm.PDL : 37.9 mGy.cm
Windowing
Windowing
Windowing
MIP
3 month, PAVSD Type 18 cc VISIPAQUE 270, 4 cc saline flush
146 bpm.DLP : 13.6 mGy.cm
Volume Rendering
6 years old40 cc Visipaque 270, 20 cc saline flush.
105bpmDLP 37.8mGy.cm
Structured report
• First Name, Last Name• Date of birth• Identification number• Scanner date
• Indication : • Age at the date of the CT scanner• Clinical context• Question
• Technique :• CT scan date of commissioning• Acquisition technique• Contrast volume, contrast name• Heart rate• Premedication• DLP (mgy.cm)
• Results :• Image quality• Segmental analysis:• Heart:• Situs abdominal (when possible) solitus or inversus• Situs atrial solitus or inversus or ambiguus• Levo/dextro/meso- cardia• Systemic veins (connection, stenosis, anatomy)• Atrio-ventricular connection, ventriculo-arterial connection• Cardiac chambers•• Great vessels:• Aorta (right or left, supra-aortic vessels, size, coarctation,
injury…)• Pulmonary arteries`(size, stenosis)• Post surgical anatomy (conduit, stent etc)• Arteriosus ductus (presence or not, size, course)• Coronary• Position of coronary ostia• Course• Stenosis / aneurysm (size, localisation)• Diameter (aneurysm, fistula)• Dominance (if possible)•• Pericardium• Thrombus•• Mediastinum / lung / oesophagus/ trachea• Associated other malformation (squelettae…)
Conclusion:Synthetic answer to the question
In summary
• Increase:
–Spatial and temporal resolution of CCT with
–Speed of data acquisition
• Decrease in radiation dose.
• Benefit/risk balance
• CT scan
–Newborns and infants: second line after echocardiography
–Adolescents: in complementary of cardiac MRI
• ALARA
Merci de votre attention