European Society of Radiology: Could you please give a detailed overview of when and for which diseases you use cardiac imaging?
Raad Tammo: We use cardiac imaging for diagnosis and confirming the diagnosis in complex congenital heart diseases after echocardiography, in myocarditis, cardiomyopathies, and myocardial infarction. We also use it for finding causes of arrhythmia, coronary artery diseases, for assessing myocardial viability, heart failure, post-surgery and post-treatment follow up, in acute cases, such as pulmonary embolism, aortic dissections and aneurysms etc.
ESR: Which modalities are usually used for what?
RT: We usually use CT for extra-cardiac vascular anatomy in paediatric and adult patients with congenital heart diseases and sometimes in case of complications after surgery; in coronary artery diseases, vascular injuries, pulmonary embolism, aortic dissections and aneurysms, valvular heart disease before surgery, like transcatheter aortic valve implantation (TAVI).
We use MRI to show the intracardiac anatomy in congenital heart diseases as a complement to echocardiography, and in post-surgery follow-up; for detecting the coronary artery origin anomalies mostly in paediatric patients and the diagnosis and monitoring of right ventricular disorders. We also use it to assess both QP:QS (pulmonary blood flow = QP, systemic blood flow = QS, to determine the magnitude of a cardiovascular shunt), valves and vessel’s flow, and myocardial viability or hibernation. Furthermore, for a myocardial function to diagnose and follow-up of patients with myocarditis and cardiomyopathies, infarction, myocardial changes in systemic diseases, noncompaction myocardium, etc. Finally, we use it for the assessment of both pericardial diseases and cardiac tumours and valvular diseases. Also, we do stress-MRI.
ESR: What is the role of the radiologist within the ‘heart team’? How would you describe the cooperation between radiologists, cardiologists, and other physicians?
RT: We cooperate very closely. We have excellent working relationships with the Divisions of Cardiology and Cardiovascular Surgery. Every day we have morning rounds with discussions of difficult cases for choosing optimal treatment or following diagnostic tests. We present all the patients imaging at the weekly cardiology and cardiovascular surgery work rounds and some of the emergency patients imaging at the morning paediatric – adult congenital work rounds. We present all the interesting cardiac CT and MRI imaging to its members at weekly image review rounds. I think that in the most challenging cases, one of the primary roles in our heart team belongs to radiologists, because usually, radiological examination provides full information for final diagnosis.
ESR: Radiographers/radiological technologists are also part of the team. When and how do you interact with them?
RT: In our team cooperation between radiologists and radiographers/radiological technologists is very close. We discuss every patient before the examination.
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?
RT: We work in a cardiac government hospital which consists of two centres. Every day we usually do about 30 examinations (20 MRI and 10 CT), and 13–17 of them are cardiac (8–10 MRI, 5–7 CT). In our department, there are six radiologists, and they all do cardiac radiology.
ESR: Do you have direct contact with patients and if yes, what is the nature of that contact?
RT: Yes, we do have direct contact with patients; we usually discuss the imaging findings with them, and possible future therapies and treatments. Also, we have contact data in a database of our institution. If we have questions according to anamnesis data, we contact patients directly.
ESR: If you had the means: what would you change in education, training and daily practice in cardiac imaging?
RT: The first which I want to change is all systems of medical university education in our country; I would like to change it like the medical curriculum in Germany, which consists of two major parts: the 2-year preclinical segment, and the 4-year clinical section. Today, Ukrainian radiology training programmes have no structured plans in cardiac imaging, and most radiology departments have no fellowship-trained cardiac radiology faculty.
Cardiovascular radiologists should have their own training programme, which includes the experience of radiation safety, medical physics and technological factors required to perform, optimise and interpret tomographic imaging. Expertise in these aspects is essential for the safe and appropriate clinical implementation of advanced diagnostic imaging techniques, and therefore radiologists and physicists have a contribution to make to shared diagnostic services. At the same time, radiologists who wish to become more closely involved in a clinical service should obtain some experience during their training within that clinical speciality, both of mechanisms of disease and the clinical utility of the diagnostic tests. There should be educational programmes that rotate fellows who want to train in cardiovascular medicine, among echocardiography, cardiovascular magnetic resonance, nuclear cardiology, and computed tomography, with non-compulsory experience for example in positron emission tomography or vascular ultrasound if it is available.
ESR: What are the most recent advances in cardiac imaging and what significance do they have for improving healthcare?
RT: The most recent advances in cardiac imaging are a package of advanced cardiac MRI visualisation and quantification software that automates a lot of the processes involved. It also uses a cloud-based platform that allows access to a significant amount of computing power needed to process cardiac cine functional data in real time. The software includes 4D flow, 2D phase contrast workflows and cardiac function measurements. The software is the first clinically available cardiovascular solution that delivers cloud-based, real-time processing of images with resolutions previously unattainable.
A significant advancement in new MRI has been the development of simplified, automated protocols and the ability of systems to do one scan, from which new software can then create several different contrasts, eliminating the need for several separate scans. The software also automates quantification measures.
New CT is designed to take quick scans that allow full imaging of the heart in just one heartbeat. There has been rapid growth in the use of 3D printing for medical education and to aid in planning and navigation of complicated surgery or interventions.
Cardiovascular imaging plays a central role in the diagnosis and treatment of cardiovascular disease.
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?
RT: Cardiac radiology is a relatively new discipline in Ukraine. When we started in 2006, it was tough to implement cardiac CT and MRI in daily practice and to explain to cardiologists and cardio surgeons that we can replace regular diagnostic methods (like angiography and scintigraphy), in most cases, to improve visualisation, make correct diagnostic and decrease radiation exposure and the amount of the contrast medium. During those twelve years, many things have changed regarding technical capabilities, and cardiac radiology is now the key diagnostic tool for many diseases and has an essential role in monitoring treatment and predicting the outcome. It has some imaging modalities in its armamentarium which have differing physical principles of varying complexity. The anatomical detail and sensitivity of these techniques are now of a high order, and the use of imaging for ultrastructural diagnostics, nanotechnology, functional and quantitative diagnostics, and molecular medicine is steadily increasing.
Transformations in technical capabilities, spatial and temporal resolution, and processing speed have led to new applications for echocardiography, nuclear imaging, CT, and CMR imaging in research and clinical practice. In nuclear imaging, the more modern cameras with CZT detectors have improved both sensitivity and efficiency; newer PET agents enable better measurements of blood flow. CT imaging has increased both the number of slices that can be obtained simultaneously to cover a larger area of the heart as well as a temporal resolution that is crucial in cardiac imaging, thus allowing imaging with much lower radiation and better accuracy. In CMR, newer sequences have permitted quantitation of collagen, scar burden, and its distribution, which can be fused with perfusion imaging and anatomy.
With such rapid progress, we might be excused for taking the future of imaging for granted. Better temporal and spatial resolution of real-time 3D echocardiography, which would improve efficiency and the reproducibility of measurements, is already on the horizon. Refinements in technology should foster the miniaturisation of ultrasound and electrocardiography into small, pocket-sized devices along with the latest in computer gadgetry and ‘apps’. We can look forward to the fusion of multiple imaging modalities, particularly in assessing structural heart disease and in the interventional arena. Another area for future technological development is that of 3D dynamic and automated mapping of valve motion. The software is being developed for better geometric assessment and, importantly, for quantitation of valve strain and stress. Going forward, I expect the observed growth and refinements in imaging technology and applications to continue unabated, from high-end equipment of CT, nuclear, CMR, 3D echocardiography, and molecular imaging to miniaturisation with hand-held devices.
ESR: Is artificial intelligence already having an impact on cardiac imaging and how do you see that developing in the future?
RT: Artificial intelligence (AI) helps to increase the speed of a cardiac MRI exam review. When an exam is performed, the system automatically identifies the anatomy and then creates all the standard views needed for diagnosis. The software also automates quantification measures. Regurgitation evaluation software offers several ways to view regurgitation, which has traditionally been difficult to assess on MRI. One view visualises blood flow velocities with arrows to show the direction of flow and a colour code to display the speed of the current. It presents very similarly to cardiac ultrasound colour flow Doppler. The software can help identify regurgitation jets, vortices, and sheer wall stresses, and offers automated quantification. In cardiovascular research, pure stress evaluation has become a significant area of interest because it is believed these stresses may play a role in the formation of atherosclerosis, the degradation of heart valve function and play a role in the progression of heart failure. So, some companies also introduced a research sheer stress analysis software package.
Artificial intelligence will play a vital role in the next couple of years. AI will not be diagnosing patients and replacing doctors; it will be augmenting their ability to find the key, relevant data they need to care for a patient and present it in a concise, easily digestible format. When a radiologist calls up a chest CT scan to read, the AI will review the image and identify potential findings immediately from the image and by combing through the patient history related to the particular anatomy scanned.
Dr. Raad Tammo is a radiologist at Ukrainian children’s cardiac centre in Kyiv, Ukraine. He has worked there for twelve years. He obtained his medical degree in 1997 from National Medical University (Kyiv, Ukraine) and after the postgraduate studies in the Medical Academy for Post-Graduate Education named P. L. Shupyk, he worked for six years in general radiology. After that, he became a paediatric radiologist with expertise in the imaging of congenital heart disease and other paediatric diseases. The clinical subjects that he studied during the last ten years were congenital heart disease and cardiac radiology. He completed a PhD in 2013. Since 2012 he has been an active researcher in foetal imaging, with a particular interest in vascular anomalies. His clinical responsibilities include teaching and supervising radiology residents and fellows. Dr. Tammo has given numerous lectures in Ukraine and Armenia as well as refresher courses at national and international meetings. He is a current member of the European Society of Radiology and the Ukrainian Society of Radiology.