Prise en charge des congénitaux Scanner cardiaque ... · Prise en charge des congénitaux Scanner cardiaque pédiatrique: consensus d’experts 2019 Karine Warin Fresse MD1 Isorni

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

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

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Prise en charge des congénitaux Scanner cardiaque ... · Prise en charge des congénitaux Scanner cardiaque pédiatrique: consensus d’experts 2019 Karine Warin Fresse MD1 Isorni