European Society of Radiology: Could you please give a detailed overview of when and for which diseases you use cardiac imaging? Which modalities are usually used for what purpose?
Andrei Skromov de Albuquerque: Regarding cardiac computed tomography (CCT), the main use is for the evaluation of coronary atherosclerosis, both the coronary calcium score (CS) and the computed tomography angiography (CTA).
CS score is most frequently used in asymptomatic patients and is indicated in patients with intermediate risk (Framingham score or global risk score) and low-risk patients who are diabetic or have a family history of coronary artery disease (CAD).
CTA is used more often in patients with suspected CAD and is indicated in symptomatic patients with intermediate pre-test probability (Diamond-Forester); patients with conflicting or inconclusive prior ischaemia tests; disagreement between clinical symptoms and previous ischaemia test results; suspected acute coronary syndrome in a patient with low/intermediate risk, normal or non-diagnostic electrocardiogram, and negative myocardial necrosis markers.
CTA is also often used for anomalous coronary investigation and congenital heart disease, patency assessment of coronary grafts and planning of transcatheter aortic valve implantation
(TAVI). Less frequently it is used for evaluation of cardiac tumours and pericardial changes.
Cardiac magnetic resonance (CMR) imaging is frequently used in the evaluation of ischaemic and non-ischaemic cardiomyopathies, cardiac function, myocardial ischaemia, pericardiopathies and cardiac tumours.
For analysis of cardiomyopathies and cardiac tumours, CMR is often requested in patients with an abnormal echocardiogram or in patients with suspected clinical signs and a normal echocardiogram. The use of CMR for the investigation of ischaemia is becoming more frequent in our daily practice, especially in those patients in which CAD has already been established and who need a functional study.
For the analysis of pericardiopathies, CMR is usually requested in those patients with acute chest pain and alteration of markers of myocardial necrosis, who do not present obstructive CAD.
ESR: What is the role of the radiologist within the ‘heart team’? How would you describe the cooperation between radiologists, cardiologists, and other physicians?
ASdA: Currently the radiologist plays a key role in the heart team, especially due to the great development of CTA and CMR in the past two decades. Both CTA and CMR are exams that provide numerous amount of information relevant to various clinical situations, and assist cardiologists and other physicians in the management of patients.
In my service, cooperation between radiologists, cardiologists and other doctors is great; most understand the main indications and limitations of these exams, which facilitates the daily practice of the radiologist. I am aware that cardiologists and other doctors consider radiologists an important partner in patient care.
ESR: Radiographers/radiological technologists are also part of the team. When and how do you interact with them?
ASdA: I have a close relationship with the technologists in my team, as I consider them a fundamental part in the flow of realisation of CTA and CMR. The quality of the exams depends directly on the technologist.
In my daily routine, I talk directly with them about technical aspects and how to optimise and improve the quality of the exams.
I hold semester classes with the whole team to recycle knowledge, present news and highlight the main mistakes that have occurred in the last months, always guiding them on how to improve patient care.
ESR: Please describe your regular working environment (hospital, private practice). Does cardiac imaging take up all, most, or only part of your regular work schedule? How many radiologists are dedicated to cardiac imaging in your team?
ASdA: I work almost exclusively with cardiovascular radiology in a tertiary hospital and in a large clinic in São Paulo, which has several units. Both the hospital and the clinic have modern equipment and offer a wide variety of cardiovascular exams, including CTA and MRI. My team has six cardiovascular radiologists.
ESR: Do you have direct contact with patients and if yes, what is the nature of that contact?
ASdA: Yes, I have direct contact with patients, especially in the hospital. I interview all patients before performing CTA and CMR, to better prepare the patient and optimise the examination. In the clinic, which has several units, I work in a coordinating report centre, and my contact with patients is less frequent.
ESR: If you had the means: what would you change in education, training and daily practice in cardiac imaging?
ASdA: I consider it extremely important for the cardiovascular radiologist to have full knowledge of all the stages of the examination, especially patient preparation and how to acquire images. These two factors should be addressed with great emphasis in training.
Post-processing training is also very important as it helps prepare the report and improves communication with the requesting physician. The radiologist who leads all the stages of the exam offers more safety to the patient and the team, and can optimise and increase the diagnostic capacity of the exams.
In daily practice, I think it is very important to have frequent dialogue with requesting physicians, and to attend clinical meetings and meetings with the cardiovascular radiology team.
ESR: What are the most recent advances in cardiac imaging and what significance do they have for improving healthcare?
ASdA: High temporal resolution tomography allows us to perform the examinations on patients with higher heart rate and arrhythmia, to ease the control of the heart rate and reduce the amount of medication use. In the future, heart rate control may no longer be necessary.
Fractional Flow Reserve by CTA is also a great advance. A limitation of CTA is to identify whether a significant atherosclerotic plaque determines haemodynamic repercussion, as it is an anatomical study. The FFR-CT will allow the characterising of the haemodynamic impact of stenosis, combining functional and anatomical information into one single examination.
Molecular contrasts are probably one of the main bets for the future of cardiac imaging. The use of molecular contrast that binds to specific structures, such as the endothelium under hypoxia or an atheroma plaque with a greater chance of instability, provides information that would increase the diagnostic accuracy of cardiac exams.
CMR Sequences in Free Breathing are another example of major progress. CMR is a tiresome examination, which requires patient collaboration and apnoea capacity. CMR in free breathing would make the exam much quicker and more comfortable. However, we have not yet been able to obtain free breath sequences with as good a quality as the sequences obtained with apnoea. But we expect the sequences in free breathing to make significant advances.
Other developments worth mentioning are 4D-Flow – the flow analysis of any structure of the block of images obtained – and automated post-processing software, which provides greater reporting standardisation, increased efficiency and quantitative analysis.
ESR: In what ways has the specialty changed since you started? And where do you see the most important developments in the next ten years?
ASdA: The main modifications have been the development of faster equipment with better image quality, lower radiation dose in CTA and new sequences in CMR. The development of the RIS/PACS system and of best quality post-processing software have also really impacted cardiac imaging.
Over the next ten years, I see even more important developments in faster CTA acquisition with lower radiation dose and excellent image quality; more advanced techniques and software for the analysis of myocardial perfusion by CTA and CMR. As mentioned above, I expect more development in molecular contrasts and CMR specific sequences for atheroma plaque or shear stress analysis, for example, as well as in CMR sequences in free breathing. Magnetic resonance angiography of the coronary arteries will also help improve cardiac imaging.
ESR: Is artificial intelligence already having an impact on cardiac imaging and how do you see that developing in the future?
ASdA: I still do not know the relevant impact of artificial intelligence on cardiac imaging. There is currently more automated software that makes it easier to analyse the exams, but they are still very dependent on the action of the radiologist.
In the future, I imagine that artificial intelligence will play a relevant role in the post-processing of images, with automated quantitative analysis; in the acquisition of images, with dynamic adaptation of technical parameters and selection of protocol based on patient information. It will also impact automatic association of the results of different examinations, and help to automatically classify exams with greater rigour into the work list.
Dr. Andrei Skromov de Albuquerque is a cardiovascular radiologist of the Fleury group and the German Hospital Oswaldo Cruz in São Paulo, Brazil, and a member of the Colégio Brasileiro de Radiologia e Diagnóstico por Imagem (CBR). He obtained his medical degree and did his residency in radiology at the Medical School of the University of São Paulo, after which he specialised in cardiovascular radiology at the Heart Hospital in São Paulo. Since 2009 he has been working predominantly with cardiovascular radiology. He is coordinator of the cardiovascular radiology studies group of the São Paulo Radiology Society (SPR), the cardiovascular radiology module of the Jornada Paulista de Radiologia (JPR – the largest congress of radiology in Latin America), the National Meeting of Cardiac Radiology (the largest cardiac radiology event in Latin America) and the fellowship programme of the Fleury Group. Dr. Skromov de Albuquerque participates actively as a speaker at several radiology and cardiology congresses and meetings in Brazil, as well as in refresher courses and training for residents and doctors interested in this area. He works exclusively with CT and MR, both cardiac and vascular, and his main areas of study are myocardial perfusion, atheromatous plaque and compressive syndromes. He is a reviewer of the Brazilian Archives of Cardiology, the journal of the Brazilian Society of Cardiology.