European Society of Radiology: Could you please give a detailed overview of when and for which diseases you use cardiac imaging?
Katarzyna Gruszczynska: There are many indications for cardiac imaging nowadays, and non-invasive techniques like cardiac CT and MRI have been around for a while. They are used both in diagnosis and prognosis of coronary artery disease (CAD); suspected or known CAD is the main indication for imaging. Another reason is for suspicion of myocarditis and evaluation of cardiomyopathies and cardiac insufficiency. Valve diseases which are congenital or acquired also require imaging, especially before an intervention. Imaging of great vessels helps to diagnose the cause of chest pain, for example in patients with suspected pulmonary embolism or aortic aneurysms. Patients with atrial fibrillation before ablation are often referred to cardiac imaging to depict the pulmonary veins. Of course, echocardiography is the first technique for cardiologists, as it is totally non-harmful and can be performed in every clinical situation. Cardiac catheterisation is used before coronary intervention in patients with CAD, however, indications from non-invasive cardiac imaging are growing all the time.
ESR: Which modalities are usually used for what?
KG: Generally coronary CT angiography is used for visualisation of coronary arteries: this means the exclusion or confirmation of coronary narrowing or occlusion in patients with stable angina and atypical chest pain. On the other hand, in patients with acute chest pain, CT is able to exclude or confirm CAD or to depict the non-cardiac cause of chest pain. CT coronary angiography is used in patients with suspicion of a coronary anomaly, as it depicts the detailed anatomy of coronary arteries. Also, patients after coronary intervention (angioplasty or stenting) or patients after bypass surgery are referred to CT coronary angiography to exclude stent restenosis or thrombosis or to prove bypass patency. Calculation of volume and amount of calcified atherosclerotic plaques (Calcium Score in CT) is used to assess the risk of CAD and the risk of cardiac events in patients with an intermediate pre-test probability of CAD. Pulmonary CT angiography is the method of choice to detect pulmonary embolism, and CT aortography is used to visualise aortic aneurysm, aortic dissection and other acute aortic syndromes, before surgery or endovascular treatment – TAVI and as a follow-up technique.
The main indication of cardiac MRI is the suspicion of myocarditis, coronary artery disease and cardiomyopathy. MRI stress perfusion with adenosine is frequently used to confirm or exclude CAD. Cardiac MRI is used to differentiate the cause of a cardiac chambers insufficiency. MRI is able to depict fibrosis as a substrate of arrhythmia. Cardiac MRI is used to evaluate cardiac morphology in detail in children with congenital heart disease before cardiac surgery or intervention and then as a follow-up technique throughout their lives and also in adults.
ESR: What is the role of the radiologist within the ‘heart team’? How would you describe the cooperation between radiologists, cardiologists, and other physicians?
KG: The radiologist is a very important part of the heart team. At first, they often decide which modality – CT or MRI – should be used for which patient, depending on the clinical scenario. During the examination, radiologists tailor the examination protocol to the patient’s needs. It requires the knowledge of both cardiac radiology technique and cardiac pathology. Then they describe the exam and discuss the results with the clinicians – cardiologists, interventional cardiologists and cardiosurgeons. This cooperation is not always easy, always challenging, however in my opinion the heart team is the only way to integrate the knowledge coming from different specialisations for the benefit of their patients.
ESR: Radiographers/radiological technologists are also part of the team. When and how do you interact with them?
KG: Good cooperation between radiologists and radiographers is a prerequisite for the proper organisation of a cardiac imaging department. As cardiac imaging is difficult, radiographers are a very important part of the team. Radiographers are actually the ones who are responsible for the technical part of cardiac MRI and CT, and do the everyday clinical work: operating the machine, often struggling with artefacts to assess the best examination quality. I am very happy to work with fantastic radiographers, we perform cardiac exams together side by side.
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?
KG: I work in a paediatric university hospital, so cardiac radiology is only part of my everyday clinical practice. I perform ultrasound, x-ray, CT and MRI on paediatric patients. However, cardiac radiology is very demanding, as in our hospital (Upper Silesian Children’s Centre in Katowice, Poland), children with severe congenital heart diseases (i.e. HLHS) are diagnosed and treated. It requires the cooperation of radiologists with cardiologists, cardiac surgeons and interventional cardiologists. The cath lab is placed in our department (actually, the same machine is used for cardiac and for example brain vessel interventions in children), so we have everyday contact with the heart team. As radiologists, we follow children with congenital cardiac anomaly often starting from a chest x-ray, then with CT and/or MRI before the intervention or cardiac surgery. Two of seven radiologists from our team are involved in cardiac radiology, also performing CT coronary angiographies in adult children and cardiac MRI in private practice.
ESR: Do you have direct contact with patients and if yes, what is the nature of that contact?
KG: Yes, performing ultrasound exams on children means being in direct contact with them and their parents. Also contrast exams are performed by radiologists and require a conversation with children and parents before the exam – to explain what we are going to do, and after to discuss the results. Before cardiac CT and MRI, we talk to patients to gain knowledge about their cardiac history and to ensure there is no contraindication. Good patient collaboration is crucial during cardiac scans. Afterwards, I often show the images to the patients, especially after MRI as patients are curious what their heart looks like.
ESR: If you had the means: what would you change in education, training and daily practice in cardiac imaging?
KG: I am personally very grateful to Professor Gabriel Krestin from Erasmus Medical Center who invited me to Rotterdam – I spent a whole year there and it was the milestone in my cardiac radiology education and it helped me a lot with my university career. Now it is far more easy than it used to be thanks to ESR and ESCR which organise courses and fellowships for residents and young radiologists interested in cardiac imaging. However, for radiologists from Eastern Europe, it is still not so easy to stay abroad for a longer time for a fellowship. So I think that the short workshops and hands-on visits could be more available in dedicated cardiac centres.
Also in my country, training radiographers in cardiac radiology is very difficult – here a great financial barrier exists. For Polish radiographers also the language could be the problem.
And last but not least, as I am getting older I also notice that technology is advancing all the time, and for me, it is not so easy to follow it anymore. There are a lot of educational opportunities for young people, but not for seniors – so I dream about the organised long-life education for radiologists at all stages of life.
ESR: What are the most recent advances in cardiac imaging and what significance do they have for improving healthcare?
KG: The recent advances in cardiac radiology are presented each year during the ESCR annual meeting. The last one took place in Geneva in May 2018 with Professor Jens Bremerich as president. This year I was impressed by the dual energy and spectral imaging in CT – it is already used on regular basis to assess cardiac and pulmonary perfusion, however, its possibilities go far beyond this. Spectral CT by virtual material decomposition enables the detailed evaluation of tissue character. It also helps to further reduce the dose in cardiac CT – cardiac imaging with sub-mSv dose is another great achievement of the last few years. The other advances in cardiac imaging are non-invasive calculation of coronary flow reserve in patients with suspected CAD, implementation of T1 and T2 mapping for tissue characterisation in cardiac MRI and integration of 3D printing based on cardiac imaging in cardio surgery.
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?
KG: I started from axial CT, so the possibility of vessel and cardiac imaging both in CT and MRI is a miracle for me. To be a modern radiologist means to subspecialise to become an equal partner for clinicians: cardiologists, neurosurgeons, oncologists and so on – it requires really a deep knowledge. On the other hand, I am afraid that non-invasive imaging is the cause of the decreasing number of interventional radiologists – we partially lost the catheter angiography skills of an earlier generation of radiologists – at least in cardiac imaging. The most important developments in cardiac radiology in the next years, in my opinion, is the successful organisation of 24h cardiac radiology service for acute patients.
ESR: Is artificial intelligence already having an impact on cardiac imaging and how do you see that developing in the future?
Artificial intelligence is the challenge of modern radiology – the amount of data which could be stored and analysed is enormous and it is a revolutionary possibility for research. On the other hand, deep learning raises the question of whether radiology as a specialisation would survive this revolution. In my opinion, the interventional radiologists could feel safe. For the others, the solution to surviving is to keep in contact with the patients, not only images and to stay a part of the real, not the virtual clinical environment.
Dr. Katarzyna Gruszczynska is Assistant Professor of Radiology and Head of the Division of Diagnostic Imaging at the Medical University of Silesia, in Katowice, Poland (one of three divisions within the Department of Radiology and Nuclear medicine). She received her MD in 1991 and her PhD in 2003, both from the Medical University of Silesia. She started her medical career in internal medicine. Since 1996 she has worked at the Department of Radiology and Nuclear Medicine at the University Hospital no 6, where she became Head of the Department of Diagnostic Imaging & Interventional Radiology in 2011. This hospital is a University paediatric centre, so the everyday clinical practice is dedicated to paediatric radiology, including cardiovascular imaging. In Poland there is only one specialisation for radiologists, general radiology. Further interest depends on the profile of the hospital (for Dr. Gruszczynska it is paediatric radiology) and the passion – it means cardiovascular imaging for her. Dr. Gruszczynska has published 41 scientific papers and 15 book chapters; at ECR 2007 she received a Certificate of Merit for her educational exhibit on coronary calcium scoring. She has participated in numerous research projects, both in Poland and internationally, and in 2006/2007 she did a one-year-fellowship in cardiac radiology at the Erasmus Medical Center in Rotterdam, the Netherlands. Dr. Gruszczynska is a member of the Membership Committee of the European Society of Cardiovascular Radiology (ESCR) and served as Chairperson of the ESCR Annual Meeting in Krakow, Poland, in 2016.