Cardiac CT in Pediatric

Patients
Marilyn J. Siegel, M.D.
Mallinckrodt Institute of Radiology
Washington University School of Medicine
St. 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

Right arch Double Arch

Neonate Adolescent
 Pulmonary Sling:
Left pulmonary artery arises from right pulmonary artery

Neonate
Case from J. Schoepf
 Aortic Coarctation
10-day old girl with CHF; 8 cc contrast,

3D CT
CT
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
ASD

ASD/VSD
Post ASD repair
 Post-operative Evaluation:

Grafts subclavian arteries to Graft right atrium

pulmonary arteries to pulmonary artery
 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 Pseudoaneurysm

CT prompted angiography 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 Cath 20-30 mSv
– (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 Monitoring
Radiation 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
350

Contrast Enhancement (HU)

5 mL/s
300 3mL/s
250 1mL/s

200

150

100
Bae 2002
50

0
0 25 50 75 100 125 150 175 200
Time (sec)

 injection rate increases contrast enhancement

  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
Varying iodine concentrations
Total iodine mass and flow rate constant (5mL/s)
350
400 mgI/mL
300 350 mgI/mL
Aortic CE (HU)

250 300 mgI/mL

200
150
Bae 2002 100
50
0
0 10 20 30 40 50
Time (sec)

 iodine concentration =  contrast enhancement

 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