European Society of Radiology: Could you please give a detailed overview of when and for which diseases you use cardiac imaging?
Sutipong Jongjirasiri: Computed tomography (CT) and magnetic resonance imaging (MRI) are the modalities that are most frequently used in cardiac imaging. I have only worked with cardiac CT angiography (CTA), which is generally used in:
- Ruling out coronary artery stenosis
- Diagnosing patients with atypical chest pain or dyspnoea
- Coronary artery calcium (CAC) screening
- End-stage renal disease (ESRD) with preoperative evaluation (in some cases that have a high risk of cardiac artery disease, preoperative evaluation of coronary CTA before renal transplant will be requested; these cases are increasing)
- Preoperative transcatheter aortic valve replacement (TAVR) planning
- Other indications including post-operative coronary artery bypass graft (CABG), Blalock-Taussig shunt in congenital heart disease (CHD), ruling out CHD in adults, for instance coronary artery anomalies, patent ductus arteriosus (PDA) and arteriovenous fistula or ruptured aneurysm of sinus of Valsalva, and cardiac tumour
ESR: Which modalities are usually used for what?
SJ: Besides cardiac CTA, cardiac MRI is usually used in adults to assess myocardial perfusion, perform stress MR and evaluate cardiac function. Myocardial contrast delayed enhancement magnetic resonance imaging (MDE) is also a common examination.
Nuclear doctors use nuclear examinations, such as positron emission tomography (PET) or single photon emission computed tomography (SPECT), to evaluate myocardial perfusion.
ESR: What is the role of the radiologist within the ‘heart team’? How would you describe the cooperation between radiologists, cardiologists, and other physicians?
SJ: Cardiologists carry out most adult cardiac MRI examinations and diagnostic radiologists perform all adult cardiac CT studies. Cooperation between both specialists is good.
Paediatric cardiac MRI and CTA studies are usually done by another senior radiologist, whose cooperation with paediatric cardiologists is excellent.
Cooperation between radiologists and nuclear physicians for PET or SPECT studies is also excellent.
ESR: Radiographers/radiological technologists are also part of the team. When and how do you interact with them?
SJ: It’s really teamwork between expert radiographers and radiologists. Both specialists establish protocols, and if there is any problem, the radiographers will consult the radiologists.
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?
SJ: I do body imaging focusing mainly on cardiac CTA, and body CTA for four and a half days a week. The rest of the week, I perform transarterial chemoembolisation (TACE) as an interventional radiologist.
Four radiologists are dedicated to cardiac imaging at my institution: one does cardiac CT, another, paediatric CT and cardiac MRI, another does nuclear scans and one senior staff takes care of both adult and paediatric cardiac CT and MRI.
ESR: Do you have direct contact with patients and if yes, what is the nature of that contact?
SJ: Yes I do, for instance, to prepare the patient before scanning, and establish high-risk patient guideline protocols, such as contrast allergy and in patients with renal insufficiency a low glomerular filtration rate (GFR).
ESR: If you had the means: what would you change in education, training and daily practice in cardiac imaging?
SJ: Radiology training currently takes three years (the residency training programme for diagnostic radiology) and it takes two additional years for the body imaging fellowship. This scheme is perfect as it is.
For cardiac CTA, we have a good cooperation with cardiologists, so I wouldn’t change anything there.
ESR: What are the most recent advances in cardiac imaging and what significance do they have for improving healthcare?
SJ: I would say artificial intelligence (AI), CAC screening for the probability of cardiac disease, spectral and dual-energy CT have been the most significant developments recently. Papers have shown that dual-energy will decrease iodinated contrast as low as half the current dose while maintaining a high quality of images. This will notably be of great benefit to patients with poor renal function.
There is also interesting research going on in terms of reducing blooming calcification artefacts and improving the image quality of cardiac perfusion defect.
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?
SJ: There’s been a boom in technology, i.e. electron beam angiogram scanner, which Ramathibodi Hospital has had since 1996, 4 detectors, 16 detectors and 320 detectors CT scanners. We have also had spectral CT since 2007 at my institution, as well as advanced MRI techniques and software on both 1.5 and 3T scanners. These technological advances have changed cardiac radiology daily practice, and general radiologists have to update their knowledge and need to work closely with clinicians.
In the next ten years, developments will be driven by artificial intelligence (AI), radiation reduction technology and contrast administration to patients with increasing accuracy of diagnosis.
ESR: Is artificial intelligence already having an impact on cardiac imaging and how do you see that developing in the future?
SJ: In the case of TAVR planning, software using AI can be very accurate, since AI can train the software to find the aortic annulus plane.
Dr. Sutipong Jongjirasiri is Associate Professor and a radiologist in the cardiovascular and interventional unit of the department of radiology at Ramathibodi Hospital, Bangkok, Thailand. He specialised in diagnostic radiology at Chulalongkorn University, Bangkok, and completed a fellowship in computed tomography and magnetic resonance imaging at the Ramathibodi Hospital, Mahidol University, in Bangkok. Dr. Jongjirasiri is the current President of the Thai Society of Vascular Interventional Radiology (TSVIR). He has spoken and attended numerous conferences worldwide, including the European Congress of Radiology (ECR).