Download Austin Wong Cardiac Imaging

5/1/2015
I have no financial disclosures.
Pediatric Cardiac Imaging:
Why, Who, What, When and Where
I do plan to discuss the off-label use of gadolinium
contrast for pediatric cardiac MRI/MRA
Austin H Wong, MD FACC, FAAP
May 22, 2015
HILTON HEAD ISLAND, SC
Goals
WHY Image the Heart?
Why is this baby blue?

Discuss the five W’s but not the H (how)

Review common cardiac imaging modalities
Strengths, Limitations, Liabilities

Discuss new appropriate use criteria for initial
pediatric echocardiography

Apply guidelines to several common pediatric
clinical scenarios
Bradford Cox, Deerhunter lead singer
•
Are these symptoms of
CHF?
Does this patient
have underlying
heart disease
Are there risk factors for
sudden death?
Shane Pope, Georgetown Fury Youth Basketball
1
5/1/2015
Goals of Imaging
WHAT tests are available?
Ionizing Radiation
 Röentgenography
 Angiography
 CT Scan
 Nuclear scans

Define the anatomy
 Assess contractility
 Follow the blood flow
 Assess myocardial viability
Röentgenography (Chest X-ray)

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Simple, convenient, and
inexpensive.
Assessment of and
monitoring for CHF:
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Cardiomegaly
Pulmonary vascularity
Associated extracardiac
anomalies
Small radiation exposure
(0.1 mSv per CXR)
Non-ionizing
 Ultrasound
 Cardiac MRI
Won’t discuss EP tests
 ECG, Holter, loop
recorders, EST, EPS
Fluoroscopy / Angiography

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Real-time visualization of
chambers, vasculature
Especially good for
small/distal vessels, e.g.
coronaries, PA branches,
collaterals (e.g. TOF)
Moderate radiation dose
(median 4.6 mSv)
Labor intensive, limited
access, invasive,
anesthesia risks
Rarely used in isolation
Coronary aneurysm due to Kawasaki disease
5/1/2015
Computerized Tomography
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Coronary-Artery Aneurysms in a 9-Year-Old Boy, 6 Years after the Diagnosis of Acute Kawasaki
Disease
Excellent anatomic resolution
Contrast allows visualization of
small vessels, e.g. coronaries
Quick, fairly accessible,
sedation rarely needed.
Newer techniques have
reduced radiation dose
(median doses 1.4-6.3 mSv)
Most common applications:
coronary anomalies, complex
CHD and aortic pathology
Burns J. N Engl J Med 2007;356:659-661
Nuclear Scans: Perfusion Imaging
Echocardiography
e.g. stress thallium, PET, lung perfusion scan

Uses radiolabelled tracers
to assess cardiac
metabolism
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e.g. viability p MI, coronary
perfusion p KD, TGA
Quantification of differential
pulmonary blood flow (e.g.
PE, branch PA stenosis).
Relatively poor spatial
resolution, moderate
radiation dose (5-18 mSv)
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Accessible, non-invasive,
potentially high resolution
Color-flow and Doppler
techniques allow
quantification of blood
velocities, pressures, some
myocardial properties
Limited by acoustic windows,
patient cooperation
TEE, contrast and sedation
overcome some limitations
but increase risk
5/1/2015
Magnetic Resonance Imaging
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WHICH Modality to Choose?
Excellent resolution for
anatomic details. Not
limited by acoustic
windows.
No ionizing radiation
Contrast allows detailed
quantification and
fibrosis detection.
Older implants / devices
maybe contraindications
Sedation required,
limited availability to
date
MR Case courtesy of Dr Frank Gaillard, Radiopaedia.org
CT Case courtesy of Dr David Cuete, Radiopaedia.org
Everyone Needs an Echo!
WHO & WHEN: Pediatric AUC Criteria
ACC/AAP/ASE/AHA/HRS/SCAI/SCMR/SOPE
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Highly accessible, can be performed portably,
No associated risks
As a result, utilization has skyrocketed
2007 American College of Cardiology Foundation
established appropriate use criteria (AUC) for
adult echocardiography, revised in 2011

Goal to improve patient care, outcomes
Improve cost-effectiveness
 Reporting of compliance mandated
for lab accreditation

100 clinical scenarios when echo might be ordered
Addresses initial outpatient echocardiography only
 Independent panel of experts rated scenarios as:
“Appropriate”, “May be appropriate”, “Rarely appropriate”
 Assumes other diagnostic tests, e.g. ECG, CXR have
been considered before echo
 Insurance companies may use statement to validate
payment, so clinicians must clearly
document symptoms prompting echo
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5/1/2015
From: ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 Appropriate Use Criteria for Initial Transthoracic
Echocardiography in Outpatient Pediatric Cardiology: A Report of the American College of Cardiology Appropriate Use
Criteria Task Force, American Academy of Pediatrics, American Heart Association, American Society of Echocardiography,
Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed
Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Pediatric Echocardiography
J Am Coll Cardiol. 2014;64(19):2039-2060. doi:10.1016/j.jacc.2014.08.003
Chest Pain
Appropriate
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Rarely Appropriate
Exertional chest pain
Non-exertional CP w/
abnormal ECG
CP w/ family history of
sudden death or
cardiomyopathy
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CP w/o other symptoms
or signs of CV disease,
benign FHx, normal ECG
Non-exertional CP w/
normal or no ECG
Reproducible CP w/
palpation or deep
inspiration
Figure Legend:
Chest Pain
Each indication is preceded with a number sign. The rating of A, M, or R is then followed by the median score in parenthesis for that particular indication.
∗See Discussion section. Abbreviations: A = Appropriate; M = May Be Appropriate; R = Rarely Appropriate; ECG = Electrocardiogram.
Date of download:
4/14/2015
Copyright © The American College of Cardiology.
All rights reserved.
From: ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 Appropriate Use Criteria for Initial Transthoracic
Echocardiography in Outpatient Pediatric Cardiology: A Report of the American College of Cardiology Appropriate Use
Criteria Task Force, American Academy of Pediatrics, American Heart Association, American Society of Echocardiography,
Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed
Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Pediatric Echocardiography
J Am Coll Cardiol. 2014;64(19):2039-2060. doi:10.1016/j.jacc.2014.08.003
Syncope
Appropriate
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Figure Legend:
Syncope
Each indication is preceded with a number sign. The rating of A, M, or R is then followed by the median score in parenthesis for that particular indication.
Abbreviations: A = Appropriate; M = May Be Appropriate; R = Rarely Appropriate; ECG = Electrocardiogram; ICD = Implantable Cardioverter Defibrillator.
Date of download:
4/14/2015
Copyright © The American College of Cardiology.
All rights reserved.
Syncope w/ abnl ECG
Family history of
sudden cardiac arrest,
SCD or AICD <50 y
Exertional syncope
Unexplained postexertional syncope
Rarely Appropriate
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Syncope w/o recent ECG
Syncope w/o other signs
or symptoms of CV dx, a
benign FHx, normal ECG
Probable vasovagal
syncope
Syncope w/ known noncardiac etiology
5/1/2015
From: ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 Appropriate Use Criteria for Initial Transthoracic Echocardiography
in Outpatient Pediatric Cardiology: A Report of the American College of Cardiology Appropriate Use Criteria Task Force,
American Academy of Pediatrics, American Heart Association, American Society of Echocardiography, Heart Rhythm Society,
Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for
Cardiovascular Magnetic Resonance, and Society of Pediatric Echocardiography
J Am Coll Cardiol. 2014;64(19):2039-2060. doi:10.1016/j.jacc.2014.08.003
Palpitations & Arrhythmia
Appropriate
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FHx of sudden cardiac
arrest/death or AICD
less than 50 years old
FHx or pers hx of
cardiomyopathy
If confirmed SVT or VT
Rarely Appropriate
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Palpitations w/o other
signs or symptoms of CV
disease, benign FHx,
normal ECG
FHx of channelopathy
PAC’s
Sinus brady/arrhythmia
Figure Legend:
Palpitations and Arrhythmias
Each indication is preceded with a number sign. The rating of A, M, or R is then followed by the median score in parenthesis for that particular indication.
∗See Discussion section. Abbreviations: A = Appropriate; M = May Be Appropriate; R = Rarely Appropriate; ECG = Electrocardiogram; ICD = Implantable
Cardioverter Defibrillator; PACs = Premature Atrial Contractions; PVCs = Premature Ventricular Contractions.
Date of download:
4/14/2015
Copyright © The American College of Cardiology.
All rights reserved.
From: ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 Appropriate Use Criteria for Initial Transthoracic
Echocardiography in Outpatient Pediatric Cardiology: A Report of the American College of Cardiology Appropriate Use
Criteria Task Force, American Academy of Pediatrics, American Heart Association, American Society of Echocardiography,
Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed
Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Pediatric Echocardiography
J Am Coll Cardiol. 2014;64(19):2039-2060. doi:10.1016/j.jacc.2014.08.003
Other Symptoms and Signs
Appropriate
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Signs/symptoms
suggestive of CHF
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Murmur
Each indication is preceded with a number sign. The rating of A, M, or R is then followed by the median score in parenthesis for that particular indication.
Abbreviations: A = Appropriate; M = May Be Appropriate; R = Rarely Appropriate.
Date of download:
4/14/2015
Copyright © The American College of Cardiology.
All rights reserved.

Respiratory distress
Poor perfusion
Failure to thrive
Oliguria
Edema
Hepatomegaly
Endocarditis signs
Central cyanosis
Rarely Appropriate
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Fatigue w/o other
symptoms or signs of CV
disease, benign FHx,
normal ECG
Acrocyanosis
5/1/2015
Systemic Disorders
Case 1
Appropriate
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Chemotherapy
Sickle-cell disease
Connective tissue dx
Genetic syndromes
assoc w/ CHD
HIV
Kawasaki disease
Rheumatic fever
Lupus
Muscular dystrophy
Systemic hypertension
Renal failure
Stroke
Storage diseases
18 yo w/ 2 week hx of exertional chest pain
Rarely Appropriate
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Obesity w/o other CV risk
factors
Diabetes mellitus
Lipid disorders
Seizures, ADHD, other
neurologic, psychiatric dx
Gastrointestinal dx NOS
Chest Pain
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Began with onset of track season,
elicited only w/ high levels of
exertion
Physical examination normal
Boston Children’s Hospital SCAMP
Standardized Clinical Assessment & Mgmt Plan
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Common, >650,000 pediatric visits annually
Cardiac etiologies rare, 0-5%
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Saleeb et al (Boston CH, Pediatrics 2011) 3,700 pts/10 yrs
Idiopathic 52%, musculoskeletal 36%, respiratory 7%, GI 3%
Cardiac 1% (SVT, pericarditis), 9/3700 had conditions putting
them at risk of SCD: myocarditis 4, AOCA 3, HCM 1, DCM 1
All CV etio identifiable by H&P, selected ECG use
No deaths from missed CV dx
High levels of pt/family anxiety
Work-up extensive, costly, low-yield
Designed to reduce practice variation, optimize
resource utilization, and improve patient care
 Originally targeted clinic pediatric cardiologists,
expanded to primary care physicians.
 OPD clinic experience showed that stress tests did not
identify any cardiac etiologies for chest pain and
should not be performed
 Holter had no role in absence of palpitations
 Echo low yield in absence of red flags
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5/1/2015
Chest Pain SCAMP
Case 1 cont’d
Friedman & Alexander, Journal of Pediatrics,
163(3):896-901, 2013
Specific history &
physical exam red
flags to prompt
subspecialty
evaluation and
cardiac imaging
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ECG read as normal
Echo performed in adult lab was read as normal
Underwent CT angiography – coronary anomaly found
WHERE: Pediatric Lab Preferred
Case 2
Kids are not little adults.
16 year old presents after two syncopal episodes
Reviews by Stanger et al (Am J Card 1999) and Ward
& Purdie (J Paed Ch Health 2001) show significant
diagnostic errors in studies performed on pediatric
patients at adult echo labs.
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Of patients going on to surgical/cath procedures, adult lab had
major errors in 44% (e.g. missed coarct, coronary aneurysms),
moderate in 28% (e.g. missed/misjudged shunts), small 12%
 No pediatric lab interpretative or technical errors
Errors tended to occur more in younger and more
complex patients.

Exertional chest pain prompts further testing
First after standing to leave classroom at school
Second while taking shower.
 Both with prodrome of nausea, dizziness, blurry vision
 Physical exam normal except for mild postural
tachycardia, +35 bpm when standing
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Like CP, syncope very common in children & teens
Like CP, elicits concern/anxiety
prompting extensive workup
5/1/2015
NCS vs. Cardiac Syncope
Syncope SCAMP
H&P + ECG will identify vast majority of cardiac syncope

History: focus on
characterizing prodrome,
setting, trigger, associated
symptoms.
 Physical exam including
orthostatics, dynamic
auscultation (r/o LVOTO),
 ECG r/o AV block, LQTS,
WPW, CMO ,sev RVH,
Brugada, etc.
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Neurocardiogenic syncope >80% of ped syncope
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Typical settings: prolonged standing, warm environment,
rising suddenly.
 Prominent prodrome (nausea, dizziness, tunnel vision)
 Pallor, brief LOC with minimal residual symptoms
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Cardiac syncope
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Acute collapse, often w/ exertion
Limited prodrome
Friedman & Alexander, J Peds, 2013
Syncope
Ritter et al (Pediatrics 2000) – 480 syncopal kids,
echo did not contribute to diagnosis in any patients,
H&P, ECG identified 21 of 22 w/ cardiac etiologies
 Saarel et al (Pediatrics 2004) – 495 patients w/ Holter,
useful only if had palpitations. No yield for isolated
syncope, pre-syncope or CP.
 Tilt-table has limited specificity (40%), poor sensitivity
(65-75%) and poor reproducibility (50-87%)
 Reassurance and education are key
to prevent recurrences.

Summary
CXR still useful for evaluation of CHF symptoms
 Angio/cath supplanted by CTA or MRA for anatomic
evaluation but still useful in guiding interventional
therapies, hemodynamic cath
 CTA especially useful for small-vessel anatomy, e.g.
coronaries, distal PA’s, aortic aneurysm, esp. in ER
 Nuclear scans – limited utility in pediatrics
 MRI – high resolution, sophisticated quantification and
myocardial viability assessment but limited by need for
anesthesia.
 Echo remains cornerstone of field
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5/1/2015
Mutton’s Law
Know What to Do and When to Do It
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“They also serve who stand and wait” – John Milton
“Because that’s where the money is” – Willie Sutton
References:
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Lots of tools available to image the heart.
 AUC and SCAMPs help guide rational use of limited
resources and will ultimately improve patient care
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Thank You!
S Anwar & RW Kavey, “Pediatric Chest Pain: Findings on Exercise Stress Testing”, Clinical Pediatrics, 51(7):659-62; 2012
RM Campbell et al, “2014 Appropriate Use Criteria for Initial Transthoracic Echocardiography in Outpatient Pediatric
Cardiology: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Academy of
Pediatrics, American Heart Association, American Society of Echocardiography, Heart Rhythm Society, Society for
Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular
Magnetic Resonance, and Society of Pediatric Echocardiography”, J Am Coll Cardiol, 64(19):2039-60; Nov 11, 2014
MMP Driessen et al, “Advances in cardiac magnetic resonance imaging of congenital heart disease”, Pediatr Radiol, 45:5-19;
2015
KG Friedman et al, “Management of Pediatric Chest Pain Using a Standardized Assessment and Management Plan”,
Pediatrics 128(2):239-45; Aug 2011
KG Friedman & ME Alexander, “Chest Pain and Syncope in Children: A Practical Approach to the Diagnosis of Cardiac
Disease”, Journal of Pediatrics, 163(3):896-901; Sept 2013
DA Kane et al, “Needles in the Hay: Chest Pain as the Presenting Symptom in Children with Serious Underlying Cardiac
Pathology”, Congenit Heart Dis, 5:366-73; 2010.
FG Meinel et al, “ECG-synchronized CT Angiography in 324 Consecutive Pediatric Patients: Spectrum of Indications and
Trends in Radiation Dose”, Pediatr Cardiol, 36:569-78, 2015
Saleeb SF et al, “Effectiveness of screening for life-threatening chest pain in children”, Pediatrics 128:e1062-8; Nov 2011
P Stanger et al, “Diagnostic Accuracy of Pediatric Echocardiograms Performed in Adult Laboratories”, Am J Cardiol, 83:90814; 1999
JT Tertter & RW Kavey, “Distinguishing Cardiac Syncope from Vasovagal Syncope in a Referral Population”, Journal of
Pediatrics, 163(6):1618-1623; Dec 2013