Cardiac CT in Pediatric Patients
Marilyn J. Siegel, M.D.Mallinckrodt Institute of Radiology
Washington University School of MedicineSt. Louis, MO. USA
FDA Questions: Contrast-enhanced Pediatric Cardiac CT
• Indications for CT
• Impact of CT on diagnosis & treatment
• Contrast-specific questions:
– Methods of determining dosing
– Limitations of contrast-enhanced CT
– Methods of safety monitoring
• Efficacy data (adults & children)
• Direction of future drug development or utilization for contrast agents in children
Cardiac CT: Basic Facts
• Need multidetector CT
• Faster imaging times
– fewer motion artifacts
• Higher spatial resolution
– 0.5 to 1.25 mm
– superb 3D images
• Better contrast enhancement
• THE USE OF CT IS INCREASING
Frequency of Contrast Usage
• Contrast mandatory
–100% of cases
• Inherent problems in children
–Small patient size
– Lack of perivisceral fat
• Poor differentiation of soft tissue structures on non-enhanced CT scans
• Solution: IV contrast
FDA Questions: Contrast-enhanced Pediatric Cardiac CT
• Indications for CT
• Impact of CT on diagnosis & treatment
• Contrast-specific questions:
– Methods of determining dosing
– Limitations of contrast-enhanced CT
– Methods of safety monitoring
• Efficacy data (adults & children)
• Direction of future drug development or utilization for contrast agents in children
Indications: Pediatric Cardiac CT
• Detection of disease or pathology –i.e., diagnosis
• Improve clinical decision making–Need for other diagnostic testing–Use of specific intervention
• No role in defining normal anatomy• No role in assessing function• Not a screening tool
Specific Disease States or Pathology
• Extracardiac great vessel anomalies
• Intracardiac shunt lesions
• Post-operative anatomy
• In children, CT is performed most often for congenital diseases
Pediatric Heart Diseases
• Common extracardiac lesions– Aortic arch anomalies
– Aortic coarctation
– Interrupted arch
– Patent ductus arteriosus
– Pulmonary artery sling
Arch Anomalies
Neonate Adolescent
Right arch Double Arch
Pulmonary Sling:Left pulmonary artery arises from right pulmonary artery
Case from J. Schoepf
Neonate
Aortic Coarctation
10-day old girl with CHF; 8 cc contrast,
3D CTCT
Patent Ductus Arteriosus
CT MR
Other Indications for Pediatric Cardiac CT
• Diagnosis of cardiac shunts
–atrial septal defects
–ventricular septal defects
• Evaluate post-operative anatomy
–usually complex cyanotic heart disease
Shunt Lesion: Septal Defects
Post ASD repairASD/VSD
ASD
Post-operative Evaluation:
Graft right atrium to pulmonary artery
Grafts subclavian arteries to pulmonary arteries
FDA Questions: Contrast-enhanced Pediatric Cardiac CT
• Indications for CT
• Impact of CT on diagnosis & treatment
• Contrast-specific questions:
– Methods of determining dosing
– Limitations of contrast-enhanced CT
– Methods of safety monitoring
• Efficacy data (adults & children)
• Direction of future drug development or utilization for contrast agents in children
Impact on Management
• Predict whether patient should undergo further invasive diagnostic testing (angiography)
• Clarify equivocal angiographic findings
• Predict whether patient needs surgery
Therapeutic Intervention:Indications for Re-operation
Leaking Baffle
CT prompted angiography
Pseudoaneurysm
Prompted surgery
FDA Questions: Contrast-enhanced Pediatric Cardiac CT
• Indications for CT
• Impact of CT on diagnosis & treatment
• Contrast-specific questions:
– Methods of determining dosing
– Limitations of contrast-enhanced CT
– Methods of safety monitoring
• Efficacy data (adults & children)
• Direction of future drug development or utilization for contrast agents in children
Contrast Dosing
• Contrast volume is determined empirically based on patient weight
• Nonionic contrast medium
–280 to 320 mg I
• Dose
–2 mL/kg (max 4 mL/kg or 125 mL)
Contrast Injection
• Power Injection
–Antecubital catheter
–Flow rate: variable
»22g 1.5 -2.0 mL/sec
»20 g 2.0 -3.0 mL/sec
»24g or central line 1.0 mL/sec
• Hand Injection:
–Peripherally positioned catheter
FDA Questions: Contrast-enhanced Pediatric Cardiac CT
• Indications for CT
• Impact of CT on diagnosis & treatment
• Contrast-specific questions:
– Methods of determining dosing
– Limitations of contrast-enhanced CT
– Methods of safety monitoring
• Efficacy data (adults & children)
• Direction of future drug development or utilization for contrast agents in children
Limitations of Contrast-Enhanced CT
• Contrast-related:
–Extravasation at injection site
–Adverse contrast reactions
• Device-related:
–Radiation exposure
Contrast-Related Risks
• Extravasation at injection site
–Power injector: 0.4%
–Manual injection: 0.3%
Kaste Pediatr Radiol 1995; 26:449
Incidence Contrast Reactions:Meta-analysis
• LOCM(NICM)
– All 1-3%
– Minor near 1%
– Major (severe) .04% (1:10,000)
– Late 5-8%
• Mortality rate - LOCM since 1980 1:100,000
Adverse Contrast Reactions:Pediatric Population
• 321 children• Questionnaire (73% return rate)• Omnipaque 300/450 (Iohexol)• Acute reactions 1.9%
– Minor (mild) – Older patients (> 24 kg)
• Late reactions 6.2%– Mild or intermediate– Younger (< 24 kg)
Mikkonen, Pediatr Radiol 1995; 25:350
Adverse Contrast Reactions
• Nonionic n=168,363 (1986-1988)• Overall prevalence of ADRS: 3.13%
– Severe 0.04%, deaths 0.004%• 70% within 5 minutes, remainder later• Prevalence by age:
– < 10 yrs: 0.4%– 10-19 yrs: 2.52%– 20-49 yrs: 4.1-4.6%– > 50 yrs: 1.5-2.6%
Katayama H. Radiology 1990; 175:621
Radiation Exposure
Radiation Risks
• CT
– 10% of all radiological procedures
– 65% effective dose of all medical x-rays• Chest X-ray 0.10 mSv• Pediatric chest CT 1-10 mSv• Adult chest CT 7-15 mSv
• Cardiac CathCardiac Cath 20-30 20-30 mSv mSv
– (3.5 min fluoro/75 sec cine)(3.5 min fluoro/75 sec cine)
Relative Risks
• To individual:– Lifetime risk of cancer: 20-25% (1 in 4 or 5)
– Added risk: 0.05% (negligible, 1 in 2000)
• To population:– 600,000 pediatric CT’s in the US / year
– Without CT: 135,000 will die of cancer
– With CT: 135,300 will die of cancer
Courtesy Jim Brink, M.D.
FDA Questions: Contrast-enhanced Pediatric Cardiac CT
• Indications for CT
• Impact of CT on diagnosis & treatment
• Contrast-specific questions:
– Methods of determining dosing
– Limitations of contrast-enhanced CT
– Methods of safety monitoring
• Efficacy data (adults & children)
• Direction of future drug development or utilization for contrast agents in children
Safety Monitoring
• Dosing
– IV contrast drawn up by technologist
– Dose verified by radiologist prior to injection
– Contrast administered by radiologist
• Procedural
– Catheter site monitored for extravasation
Mitigating & Preventing Adverse Contrast Reactions
• Identify patients at risk:
–Prior moderate contrast reaction
–Medically treated asthma
• Premedication with corticosteroids
Safety MonitoringRadiation Dose
• Directly proportional to:
–Tube current
–Kilovoltage
–Scan time
–Slice thickness
–Total number of slices
Radiation Risks: Recommendations
• Optimize CT settings–Reduce tube current and voltage–Increase table speed (mm/sec)–Limit number of scans–Use automated dose reduction technology
• Eliminate inappropriate referrals for CT
FDA Questions: Contrast-enhanced Pediatric Cardiac CT
• Indications for CT
• Impact of CT on diagnosis & treatment
• Contrast-specific questions:
– Methods of determining dosing
– Limitations of contrast-enhanced CT
– Methods of safety monitoring
• Efficacy data (adults & children)
• Direction of future drug development or utilization for contrast agents in children
Efficacy Data
• In adults, large amount of data related to CT angiography of the coronary arteries and acute aortic events
• In children, overall paucity of data
– Minimal data on aortic imaging
• Several review articles on CT angiography of congenital heart disease
Coronary Artery Stenosis
• Several studies have shown that CT allows reliable detection of coronary artery disease
• 95% sensitivity, 86% specificity
»detecting > 50% stenosis
»vessels 2-4 mm in diameter
Nieman: Circulation 2002; 106:2051 Fayad: Circulation 2002; 106:2026
Pediatric Aortic Arch Anomalies
• 22 pediatric patients
• Confirmatory studies:
– Echocardiography (n=7)
– Angiography (n=7)
– Surgery (n=8)
• Accuracy CT: 96%
– Stenotic vessels: 2 to 5 mm in diameter
Lee E, Siegel MJ. AJR, In Press
FDA Questions: Contrast-enhanced Pediatric Cardiac CT
• Indications for CT
• Impact of CT on diagnosis & treatment
• Contrast-specific questions:
– Methods of determining dosing
– Limitations of contrast-enhanced CT
– Methods of safety monitoring
• Efficacy data (adults & children)
• Direction of future drug development or utilization for contrast agents in children
Future Directions in Contrast-Enhanced CT
• Goal: To get the highest contrast enhancement with the least amount of contrast agent
• 2 main factors affect contrast enhancement:
– Flow rate or injection duration
– Iodine concentration
Injection Rate vs. Arterial Enhancement
0
50
100
150
200
250
300
350
Con
tras
t E
nha
ncem
ent
(HU
)
0 25 50 75 100 125 150 175 200
Time (sec)
1 mL/s3 mL/s5 mL/s
injection rate increases contrast enhancement
Bae 2002
Injection rate
• Higher levels of enhancement may result in smaller volumes of contrast
• But in children there is a limit how fast we can inject, because small gauge catheters and catheters in hand and foot need slower injection rate
Concentration vs. Enhancement
0
50
100
150
200
250
300
350
0 10 20 30 40 50Time (sec)
Ao
rtic
CE
(H
U)
400 mgI/mL350 mgI/mL300 mgI/mL
Varying iodine concentrations
Total iodine mass and flow rate constant (5mL/s)
iodine concentration = contrast enhancement
Bae 2002
Concentration vs. Flow Rate
• Left ventricular density (200-300 HU)
– 300 mgI/mL at 3.5 mL/sec
– 400 mgI/mL at 2.5 mL/sec
• Injecting low-concentration contrast at high flow rate or higher-concentration at lower flow rate produces similar enhancement density
Becker Appl Radiol 2003; S50
Effect of Iodine Concentration
• Implication in children
• Use of higher concentration contrast material at may result in smaller contrast volumes
• Disadvantage Viscosity (not usable > 400 mgI/mL)
• Challenge for future research
CT: Future Clinical Utilization
• Ventricular function studies based on images in systole and diastole
• Pulmonary perfusion studies
– Peak attenuation & time to peak attenuation measured
Pulmo CT: Color Coded Display
Potential for studying perfusion abnormalities associated with heart/lung disease
Summary
• Role of CT will increase
• Challenges:
–Optimize contrast enhancement
–Lower radiation dose