Congenital Heart Disease (CHD) is a birth defect or malformation of the heart which can impact the heart’s structure and function. According to the American Heart Association, nearly 36,000 babies are born with a heart defect each year. While CHD can affect both children and adults and can be life threatening, revolutionary advancements in diagnosis and surgery have made treatment and reparation of such defects possible. In 2008, over one million people with CHD had survived through adulthood.

Cardiac Catheterization is a non-surgical procedure that can be used for hemodynamic and angiographic evaluations of the structure and function of the heart, helpful in the diagnosis of CHD. Transcatheter interventions for treatment of CHD can also be performed using stents, coils, and other interventional devices.

Used in conjunction with the Toshiba Infinix-i cardiac systems, the Toshiba 3D-Digital Acquisition (3D-DA) software package allows physicians to view a three-dimensional perspective of a variety of vascular structures including the pulmonary arteries. 3D reconstruction is ideal for optimizing vessel-viewing angles prior to intervention, providing a better understanding of complex anatomy and helping to determine the proper size of interventional devices to be used for planning and treatment.

Case Study: 3D rotational angiography using 3D-DA software.

Technology: Toshiba Infinix CF-i Biplane cardiovascular cath lab using 3D-DA software.

Patient History: A 14 year old girl born with complex congenital heart disease (interrupted aortic arch, ventricular septal defect) required numerous surgical procedures beginning in early infancy which culminated in a Fontan procedure at age 4. Recently she began complaining of decreased exercise tolerance prompting a cardiac MRI which raised the possibility of a left pulmonary artery stenosis which had not been appreciated during previous cardiac catheterizations despite selective left pulmonary arteriography.

Diagnosis: During catheterization performed via a right femoral venous approach, selective 2D left pulmonary angiography failed to adequately demonstrate any stenosis. Due to the high degree of suspicion a 3D-DA was performed at 30f/s using a 206 degree rotation over a 5 second acquisition while holding respiration. Fifty milliliters of undiluted contrast were injected at a rate of 10 cc/sec to obtain the images shown in figure 1. Reconstruction took 35 seconds and post-processing took another 2 minutes to produce the images shown here. By rotating the reconstructed image 90% caudal (a view, not possible with standard angiography) physicians were able to clearly view the compression of the left pulmonary artery in a front to back orientation. Two overlapping Genesis XD stents were implanted across the area with 12 mm balloon and further dilated to 14 mm to obtain the image shown in figure 2.

In this particular case the use of 3D-DA greatly enhanced the ability to diagnose an important stenotic lesion which was undetected by 2D-DA despite multiple bi-plane acquisition imaging angles. Furthermore, using 3D-DA, post-intervention provided excellent imaging of the vessel stent interface and allowed for improved assessment of the result as well as any potential complication.

Figure 1: Pre-intervention 3D-DA of the branch pulmonary arteries in a child with a significant left pulmonary artery stenosis (arrow) after a Fontan operation. In a standard projection (LAO 21/caudal 7) the stenosis is difficult to appreciate (left), however, after rotating the image to a virtual angle (LAO 35/Cranial 71), the stenosis is clearly visible as shown by the arrow (right).

Figure 2: The same structure seen in the comparable views as above following implantation of two endovascular stents to enlarge the area. Note the excellent clarity and detail of the newly implanted stents and their relationship to the vessel wall.

Pre- (left) and post- (right) 3D-DA spins.

Images courtesy of Dr. Evan M. Zahn, M.D., Miami Children’s Hospital, Miami Florida

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At this year’s RSNA, the AHRA: The Association for Medical Imaging Management and Toshiba announced the six recipients of the second annual Putting Patients First grant program.

This year’s Putting Patients First grant program was expanded to include imaging centers and three additional grants specifically for pediatric programs. The six recipients were selected by the AHRA selection committee to receive up to $7,500 grants to fund programs, trainings or seminars aimed at improving patient care and safety in diagnostic imaging.

In its second year, this program has expanded its scope to include improving the imaging of children.  Children have special imaging needs – exposure to radiation and contrast are concerns within the industry, as is ensuring that children are well prepared for the imaging experience.  Putting Patients First will help facilities address these very specific needs.

“Grant programs like Putting Patients First are critical given today’s health care environment and the pressures hospitals face due to limited resources and other financial challenges,” said Debra A. Lopez, AHRA president, CRA, FAHRA. “This year’s winning programs demonstrated quality and innovation in patient care. They will make significant improvements to patient care and better the imaging experience for physicians and patients, alike.”

The programs funded by the AHRA/Toshiba Patient First grants include:

Children’s Healthcare of Atlanta at Egleston – Use of Bismuth Shields in All CT Exams

• Several recent publications report radiation dose reduction benefits when using bismuth shielding for pediatric patients undergoing multidectector CT. Therefore, Children’s Healthcare of Atlanta at Egleston will implement the use of bismuth shields in all patients undergoing CT examinations. Implementation of this shielding program will entail staff training, purchase of bismuth breast and thyroid shields, ongoing review of images, development of resident and parental educational programs, and a cost analysis.

Community Health Network – Pediatric CT Imaging Simulation Program

• By enabling pediatric patients to better understand the CT imaging process, radiation dose will effectively be reduced, patient comfort will be improved and the overall imaging experience will be safer. Therefore, Community Health Network will create an Internet-based simulation program to educate pediatric patients and their caregivers about the diagnostic imaging process (focused on CT).  By incorporating audio, avatars and animation through a user-friendly computer program, patients will know what to expect of the imaging process and be more comfortable and compliant during the procedure.

Memorial Hermann Outpatient Imaging Division – Improved Process Program

• Memorial Hermann’s goal is to emphasize the importance of keeping radiation dose during CT procedures as low as reasonably achievable for pediatric patients, while still maintaining good image quality. It also recognizes the need for more education for the technologists and pediatricians on pediatric radiation safety. Therefore, Memorial Hermann will implement the Improvement Process Program to: 1) document the dose electronically PACs; 2) scan once – multiphase scanning is usually not necessary in children; 3) reduce or “child-size” the amount of radiation used; 4) audit and evaluate image quality monthly; and 5) provide physician and technologist continued education.

Highline Medical Center – Improvement Project for Scheduling Inpatients for Imaging Exams

• One of Highline Medical Center’s goals is to provide a patient-centered environment that personalizes, humanizes and demystifies patient care. Therefore, Highland Medical Center is undertaking an improvement project to develop, implement and spread a process for scheduling inpatients for imaging exams to accomplish safer patient care through: 1) better communication among the staff caring for the patient; 2) increasing involvement of the patient in his/her own care; 3) better coordination between services for tests and treatments leading to streamlined clinical pathway; 4) eliminating delayed/missed or incorrect imaging exams; 5) improving patient flow to potentially decrease overall length of stay; and 6) having imaging techs rounding on patients prior to high risk, invasive or advanced imaging procedures.

Shields Health Care – Understanding and Reducing Patient Anxiety

• Shields Health Care wants to engage the patient in a common language that educates and reduces patient anxiety. Therefore, Shields Health Care will develop multi-lingual web-based tools as well as professional staff training. Phase one of the program will be to research causes and develop solutions; phase two will be to implement and cross train professionals and technical staff; and phase three will be dedicated to reflection on lessons learned and measuring program effectiveness and outcomes.

St. Patrick Hospital – Interactive Utility to Improve the Imaging Process

• Inaccurate or inappropriate exam orders contribute to increased costs to patients, staff and facilities in terms of dose, money and time. Therefore, St. Patrick Hospital will create on its intranet Web site an interactive utility that is readily accessible to all staff to provide guidance regarding appropriate imaging studies and help facilitate clear exam orders to maximize the value of imaging studies. Once the program is developed for intranet users, St. Patrick Hospital will provide a condensed version of the utility on its hospital Web site with more links to helpful information in order to improve patient understanding of the process. This version also will be a tool used by clinicians and staff when discussing exam specifics with patients.

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According to the March of Dimes, congenital heart defects affect more than 25,000 infants every year in the United States.

Imaging children has many challenges due to their unique imaging requirements compared to adults. The best benchmark for a pediatric CT scanner should include the ability to acquire images as fast as possible, with the best image quality, and at the lowest possible x-ray dose.

Aquilion ONE can capture whole anatomical regions in a single rotation of the gantry. This ability can dramatically reduce the amount of contrast, radiation and possibly the need for sedation. Aquilion ONE also comes equipped with ^SUREExposure Pediatric which incorporates the unique imaging requirements of pediatric imaging and ensures the lowest possible dose while maintaining diagnostic image quality.

Case: CTA of the chest to evaluate congenital heart defect in a 9 month old infant with respiratory distress noted at birth.

Scan Parameters: 80kV, 25mAs, 0.35 second rotation.

3D volume rendered and MPR views clearly demonstrate this double aortic arch causing stenosis of the left main stem bronchus, most likely causing the infants continued respiratory distress. 3D images can give surgeons a roadmap for intervention, making it safer and saving time. No sedation was need for this scan due to the very short scan time of 0.35 seconds.