Cardiac CT in Pediatric

Patients
Marilyn J. Siegel, M.D.
Mallinckrodt I nstitute 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
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 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
Post ASD repair
ASD/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 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 CTs 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
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50

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350
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0 25 50 75 100 125 150 175 200
Time (sec)
1 mL/s
3 mL/s
5
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
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50
100
150
200
250
300
350
0 10 20 30 40 50
Time (sec)
A
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400 mgI/mL
350 mgI/mL
300 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