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European Society of Radiology: Could you please give a detailed overview of when and for which diseases you use cardiac imaging?

Yining Wang: Cardiac imaging is used for all the heart-related diseases when imaging evaluation is needed. For primary heart diseases such as coronary artery disease, congenital heart disease, primary cardiomyopathy, neoplastic disease and pericardial disease, we use cardiac imaging for screening, diagnosis and follow-up evaluation after treatment. For secondary diseases involving the heart, we use cardiac imaging for cardiac structural and functional assessment and follow-up evaluation after treatment.

ESR: Which modalities are usually used for what?

YW: Cardiac computed tomography (CT) is the most commonly used modality for coronary artery disease, however cardiac magnetic resonance (MR) is used to evaluate previous myocardial infarction and myocardial fibrosis. Cardiac CT and MR are used in combination for congenital heart disease and neoplastic disease.

Cardiac MR is the most valuable imaging modality in the assessment of cardiomyopathy and pericardial disease.

For secondary diseases involving the heart, both cardiac CT and MR can be used in combination for both cardiac structural and functional assessment.

ESR: What is the role of the radiologist within the ‘heart team’? How would you describe the cooperation between radiologists, cardiologists, and other physicians?

YW: The radiologist’s role is like a bridge or a bond within the team. A radiologist needs to translate the imaging information into a comprehensive disease evaluation of the patient, helping cardiologists and other physicians with clinical decision-making and symptom attribution.

ESR: Radiographers/radiological technologists are also part of the team. When and how do you interact with them?

YW: Radiographers and radiological technologists are really important partners to acquire excellent image quality and complete imaging information. Before scanning, we need to interact with them comprehensively to explain what kind of disease is suspected, which part of the heart should be focused on and what exactly the information that we want to know is. If necessary, we will sit beside them and instruct them on how to perform the scan. After the scan is completed, we will read the images together, summarising the experience and deficiency.

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?

YW: Our regular working environment is hospital care and cardiac imaging takes up only part of our regular work. About ten radiologists are dedicated to cardiac imaging in our team.

ESR: Do you have direct contact with patients and if yes, what is the nature of that contact?

YW: We do have direct contact with patients if necessary, in order to understand the disease and clinical condition of the patient thoroughly and comprehensively.

ESR: If you had the means: what would you change in education, training and daily practice in cardiac imaging?

YW: We have launched reform research projects targeted in medical education, training and daily practice in cardiac imaging. Our various forms of teaching and training, such as problem-based learning (PBL), integrated medical imaging training and audience response system (ARS), and the creation of flexible teaching courseware that facilitate the curriculum have made a positive difference.

As for daily practice in cardiac imaging, we organised case discussion and intractable case learning regularly to improve the capacity of our cardiac imaging team.

ESR: What are the most recent advances in cardiac imaging and what significance do they have for improving healthcare?

YW: The most recent advances in cardiac imaging mainly include cardiac CT and MR.

Recent developments in cardiac CT technology include coronary plaque characterisation, dual-energy spectral imaging, myocardial CT perfusion, CT-derived fractional flow reserve (CT-FFR), ultra-low dose CT imaging, and so on. Detailed analysis of coronary plaque characteristics and components not only provides complementary information to coronary artery stenosis evaluation, but also reveals the risk of plaque instability and rupture.

Dual-energy spectral imaging has expanded the role of conventional CT by providing more comprehensive and accurate assessment, such as beam hardening artefacts reduction, in-stent stenosis visualisation, improvement of contrast to noise ratio, and analysis of myocardial iodine map.

Myocardial CT perfusion combined with CT-FFR is an emerging method for the assessment of functionally significant stenosis, which enables a one-stop shop of morphological and functional evaluation.

The idea of low radiation dose as the permanent focus of cardiac CT has accompanied the technical progress for the past years. All these aforementioned advancements have been promoting mutual penetration and integration, which pave the way for multi-parameter imaging as a ‘low-dose one-stop cardiac CT’.

Cardiovascular magnetic resonance (CMR) now has become the golden standard technique for evaluating myocardial function, quantifying myocardial volumes and detecting myocardial scar. The recent development in CMR includes first-pass perfusion, mapping techniques and magnetic resonance angiography.

The first-pass perfusion CMR has provided a potential alternative imaging modality for suspected CAD patients with a higher resolution without radiation exposure. It has demonstrated a superior diagnostic performance compared with single photon emission computed tomography.

The mapping techniques can perform tissue characterisation quantitatively without the need for contrast agents. T1 mapping provides a novel way to quantitatively evaluate diffuse interstitial fibrosis of the myocardium. Increased native T1 mapping is useful for detecting acute myocardial pathologies, such as oedema, infarction, and sub-acute cardiomyopathies, such as cardiac amyloidosis and hypertrophic cardiomyopathy. Newly developed T2 mapping sequences can detect and myocardial oedema, including myocarditis and myocardial infarction.

CMR also offers the promise of radiation-free imaging of the coronary arteries with or without the administration of a contrast agent, providing information with respect to luminal stenosis, plaque burden, high-risk plaque characteristics, and disease activity. CMR has the potential to provide a multi-parametric assessment of different heart diseases incorporating key information related to function, perfusion, tissue characterisation and coronary arteries.

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? Is artificial intelligence already having an impact on cardiac imaging?

YW: The most important developments of cardiac imaging over the next decade could be artificial intelligence, which will be integrated into our traditional imaging modalities and transform our existing medical practice into an intelligent model of diagnosis and treatment.

Along with the flourishing of artificial intelligence, we can see that a plurality of multicentre research works have already been launched to investigate the diagnostic performance and feasibility of automatic artificial intelligence imaging diagnosis. It can be predicted that in the upcoming future, the clinical demand-based big data analysis-radiomics is very likely to be the future of cardiac imaging, which is conducive to preoperative assessment, treatment plan, risk stratification of major adverse cardiac events and prognostic analysis. This will possibly save us from time-consuming and simple repetitive work.

Professor Yining Wang is a cardiac radiologist at the Department of Radiology, Peking Union Medical College Hospital (PUMC), Dong Cheng district, Beijing, China. She is also Professor of Radiology and PhD supervisor at PUMC, where she obtained her medical degree and specialised in radiology. Her specialty is cardiac imaging and molecular imaging using CT to study coronary diseases, MRI to differentiate cardiomyopathy, and MR and fluorescence imaging to monitor the distribution and homing of the stem cells. Professor Wang is a corresponding member of the European Society of Radiology and a member of the Radiological Society of North America. She is a reviewer for the Chinese Journal of Radiology and a member of the Molecular Imaging Committee of the Biophysical Society of China. She has received multiple awards for her work and has published over 80 publications in journals, books and book chapters.

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