Background

Cardiovascular computed tomography (CCT) has become an indispensable tool for diagnosis, procedural guidance, and long-term follow-up of patients with congenital heart disease (CHD). Current generation CT scanner platforms provide isotropic submillimeter spatial resolution and temporal resolution as low as 66 msec, allowing imaging at high pediatric heart rates. Images are obtained in a single heartbeat or fraction of a second that provide detailed 3D anatomic or 4D functional information. CCT is now an essential tool for congenital cardiac imagers, cardiologists, interventionalists, and surgeons to visualize and plan complex repairs.^1,2 Modern CT scanners enable radiation dose optimization and low diagnostic risk for CHD patients of all ages.³ This is important in a patient subset with high cumulative diagnostic risk as well as an intrinsic risk of malignancy due to congenital and/or chromosomal abnormalities.⁴ The use of CCT for CHD is considered appropriate in current CHD guidelines.^5-9 Despite the extensive and expanding use of CCT for patients with CHD, there are no defined competencies or focused educational programs specific to developing expert level proficiency for performance of CCT in CHD patients.

Current CCT Education Platforms

CCT guidelines and practice standards have been defined by cardiology and radiology imaging societies, focusing on the use of CCT for coronary assessment and to guide adult structural intervention.^10-13 Education requirements include radiation and contrast safety, injection protocols, scan performance, interpretation, and reporting. CCT board certification is possible from a cardiology or radiology background. Review courses include didactic lectures, sample questions and mentored hands-on workstation cases to facilitate achievement of Level 1, Level 2 (Independent) and Level 3 (Advanced) proficiency. Competency is achievable through fellowship training or through clinical pathways for practicing cardiac imaging physicians. Standards for continued clinical competence and mechanisms for Continuing Medical Education (CME) have been established.^11,14

Minimal standards for interpretation of simple CHD lesions were included in the recent Society of Cardiovascular Computed Tomography (SCCT) training guidelines.¹¹ Focused CCT didactics are not routinely included in categorical pediatric cardiology fellowship training programs and CCT is not included as a modality in the guidelines for pediatric cardiology advanced imaging fellowships.¹⁵ CCT clinical and/or didactic experiences in pediatric cardiac cross-sectional imaging are required by the Accreditation Council for Graduate Medical Education (ACGME) for pediatric radiology fellows but without specific guidelines for training or proficiency for CHD.¹⁶ There is an urgent need for categorical and advanced imaging fellowship training recommendations, definition of core competencies, a curriculum for both fellows and practicing physicians, and an educational platform for beginner to expert level proficiency in CHD CCT performance.

Potential Workforce for Congenital CCT

Congenital cardiac imaging is currently performed by pediatric and adult radiologists and cardiologists. Since 2000, there are more adult than pediatric patients with CHD, and an ever-increasing number are >60 years old who may have both congenital and acquired cardiovascular disease.^17-19 The current potential workforce for congenital imaging based on board certification indicates that pediatric imagers are a minority in both cardiology and radiology. Annual scientific sessions at radiology and cardiology meetings may include sessions on congenital cardiac imaging. The small attendance of those currently dedicated to this field at these large meetings makes it difficult to provide the extent and depth of content required for appropriate training.

Obstacles, Opportunities and a Proposed Way Forward

Advanced imaging in CHD is time consuming and current reimbursement is not consistent with workload per case. The current practice of CCT in CHD is highly variable in terms of both quality and diagnostic risk. However, excellence in congenital CT imaging may be possible if we incorporate the following recommendations:

1. All congenital cardiac imaging modalities are complimentary, each optimized when other modalities are of highest quality.
2. Cardiologists and radiologists may perform congenital CCT, but standards need to be established. There are knowledge gaps at the intersection of adult and pediatric cardiology and radiology.
3. Standards for clinical expectations including 3D reconstructions and post-processing need to be established to support imaging clinicians who do this work. Future efforts to optimize reimbursement to reflect the time intensive workload per case are needed.
4. CCT technologist excellence is critical to the imaging team. Educational platforms specific for the development of CHD CCT technologist expertise should be established.
5. Multi-modality comparisons of risk and accuracy are lacking in CHD patients. The establishment of a multi-institutional and multi-modality diagnostic research platform is needed to inform the optimal use of imaging modalities in CHD.
6. A multi-society education collaboration has the potential to combine resources for this small but specialized imaging subset.

Diagnostic accuracy and refinement of CCT for CHD through the establishment of training guidelines will have important quality implications. Our patients with congenital and structural heart disease deserve our collaborative best.

References

1. Han BK, Rigsby CK, Leipsic J, et al; Society of Cardiovascular Computed Tomography; Society of Pediatric Radiology; North American Society of Cardiac Imaging. Computed tomography imaging in patients with congenital heart disease, part 2: technical recommendations. An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT): endorsed by the Society of Pediatric Radiology (SPR) and the North American Society of Cardiac Imaging (NASCI). J Cardiovasc Comput Tomogr 2015;9:493-513.
2. Han BK, Rigsby CK, Hlavacek A, et al; Society of Cardiovascular Computed Tomography; Society of Pediatric Radiology; North American Society of Cardiac Imaging. Computed tomography imaging in patients with congenital heart disease part I: rationale and utility. An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT): endorsed by the Society of Pediatric Radiology (SPR) and the North American Society of Cardiac Imaging (NASCI). J Cardiovasc Comput Tomogr 2015;9:475-92.
3. De Oliveira Nunes M, Witt DR, Casey SA, et al. Multi-institution assessment of the use and risk of cardiovascular computed tomography in pediatric patients with congenital heart disease. J Cardiovasc Comput Tomogr 2021;15:441-48.
4. Lupo PJ, Schraw JM, Desrosiers TA, et al. Association between birth defects and cancer risk among children and adolescents in a population-based assessment of 10 million live births. JAMA Oncol 2019;5:1150-58.
5. Doherty JU, Kort S, Mehran R, et al. ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2019 appropriate use criteria for multimodality imaging in the assessment of cardiac structure and function in nonvalvular heart disease: a report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and the Society of Thoracic Surgeons. J Am Coll Cardiol 2019;73:488-516.
6. Sachdeva R, Valente AM, Armstrong AK, et al. ACC/AHA/ASE/HRS/ISACHD/SCAI/SCCT/SCMR/SOPE 2020 appropriate use criteria for multimodality imaging during the follow-up care of patients with congenital heart disease: a report of the American College of Cardiology Solution Set Oversight Committee and Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, 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 2020;75:657-703.
7. Stout KK, Daniels CJ, Aboulhosn JA, et al. 2018 AHA/ACC guideline for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019;73:e81-e192.
8. Marelli A, Beauchesne L, Colman J, et al. Canadian Cardiovascular Society 2022 guidelines for cardiovascular interventions in adults with congenital heart disease. Can J Cardiol 2022;38:862-96.
9. Baumgartner H, De Backer J, Babu-Narayan SV, et al; ESC Scientific Document Group. 2020 ESC guidelines for the management of adult congenital heart disease. Eur Heart J 2021;42:563-645.
10. Narula J, Chandrashekhar Y, Ahmadi A, et al. SCCT 2021 expert consensus document on coronary computed tomographic angiography: a report of the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr 2021;15:192-217.
11. Choi AD, Thomas DM, Lee J, et al. 2020 SCCT guideline for training cardiology and radiology trainees as independent practitioners (Level II) and advanced practitioners (Level III) in cardiovascular computed tomography: a statement from the Society of Cardiovascular Computed Tomography. J  Cardiovasc Comput Tomogr 2021;15:2-15.
12. American College of Radiology. ACR -SPR practice parameter for performing and interpreting diagnostic CT. Resolution 9 (acr.org). 2023. Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/CT-Perf-Interpret.pdf. Accessed 04/10/2023.
13. American College of Radiology. ACR-NASCI-SPR practice parameter for the performance and interpretation of cardiac CT. Resolution 45 (acr.org). 2021. Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/CardiacCT.pdf. Accessed 04/10/2023.
14. American College of Radiology. ACR practice parameter for continuing medical education CME. Resolution 5 (acr.org). 2022. Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/CME.pdf. Accessed 04/10/2023.
15. Srivastava S, Printz BF, Geva T, et al. Task force 2: pediatric cardiology fellowship training in noninvasive cardiac imaging. J Am Coll Cardiol 2015;66:687-98.
16. ACGME Program Requirements for Graduate Education in Diagnostic Radiology (acgme.org). Available at:  https://www.acgme.org/globalassets/pfassets/programrequirements/420_diagnosticradiology_2022v2.pdf. Accessed 4/10/23.
17. Mazor Dray E, Marelli AJ. Adult congenital heart disease: scope of the problem. Cardiol Clin 2015;33:503-12,vii.
18. Mylotte D, Pilote L, Ionescu-Ittu R, et al. Specialized adult congenital heart disease care: the impact of policy on mortality. Circulation 2014;129:1804-12.
19. Khairy P, Ionescu-Ittu R, Mackie AS, Abrahamowicz M, Pilote L, Marelli AJ. Changing mortality in congenital heart disease. J Am Coll Cardiol 2010;56:1149-57.

Clinical Topics: Cardiovascular Care Team, Congenital Heart Disease and Pediatric Cardiology, Noninvasive Imaging, Congenital Heart Disease, CHD and Pediatrics and Imaging, CHD and Pediatrics and Quality Improvement, Computed Tomography, Nuclear Imaging

Keywords: Cardiovascular Diseases, Heart Rate, Follow-Up Studies, Workload, Imaging, Three-Dimensional, Motivation, Radiology, Curriculum, Heart Defects, Congenital, Certification, Radiologists, Workforce, Accreditation, Surgeons, Multicenter Studies as Topic, Fellowships and Scholarships, Tomography, Emission-Computed

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