ACR Appropriateness Criteria® Congenital or Acquired Heart Disease.

Pediatric heart disease is a large and diverse field with an overall prevalence estimated at 6 to 13 per 1,000 live births. This document discusses appropriateness of advanced imaging for a broad range of variants. Diseases covered include tetralogy of Fallot, transposition of great arteries, congenital or acquired pediatric coronary artery abnormality, single ventricle, aortopathy, anomalous pulmonary venous return, aortopathy and aortic coarctation, with indications for advanced imaging spanning the entire natural history of the disease in children and adults, including initial diagnosis, treatment planning, treatment monitoring, and early detection of complications. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Dyspnea-Suspected Cardiac Origin (Ischemia Already Excluded): 2021 Update.

Dyspnea is the symptom of perceived breathing discomfort and is commonly encountered in a variety of clinical settings. Cardiac etiologies of dyspnea are an important consideration; among these, valvular heart disease (Variant 1), arrhythmia (Variant 2), and pericardial disease (Variant 3) are reviewed in this document. Imaging plays an important role in the clinical assessment of these suspected abnormalities, with usually appropriate procedures including resting transthoracic echocardiography in all three variants, radiography for Variants 1 and 3, MRI heart function and morphology in Variants 2 and 3, and CT heart function and morphology with intravenous contrast for Variant 3. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Radiologic review of acquired pulmonary vein stenosis in adults.

Acquired pulmonary vein stenosis (PVS) is an uncommon occurrence in adults, but one that carries significant morbidity/mortality. PVS can be secondary to neoplastic infiltration/extrinsic compression, non-neoplastic infiltration/extrinsic compression, or iatrogenic intervention. This article: (I) reviews the common causes of acquired PVS; (II) illustrates direct and indirect cross-sectional imaging findings in acquired PVS (in order to avoid misinterpretation of these imaging findings); and (III) details the role of imaging before and after the treatment of acquired PVS.

Staging Lung Cancer: Regional Lymph Node Classification.

This article reviews regional lymph node assessment in lung cancer. In the absence of a distant metastasis, the absence or location of lung cancer spread to a regional mediastinal lymph node affects treatment options and prognosis. Regional lymph node maps have been created to standardize assessment of the N descriptor. The International Association for the Study of Lung Cancer lymph node map is used for the standardization of N descriptor assessment. CT, PET/CT with fluorodeoxyglucose, endobronchial ultrasound-guided and/or esophageal ultrasound-guided biopsy, and mediastinoscopy are common modalities used to determine the N descriptor.

Cross-Disciplinary Analysis of Lymph Node Classification in Lung Cancer on CT Scanning.

BACKGROUND: Accurate and consistent regional lymph node classification is an important element in the staging and multidisciplinary management of lung cancer. Regional lymph node definition sets-lymph node maps-have been created to standardize regional lymph node classification. In 2009, the International Association for the Study of Lung Cancer (IASLC) introduced a lymph node map to supersede all preexisting lymph node maps. Our aim was to study if and how lung cancer specialists apply the IASLC lymph node map when classifying thoracic lymph nodes encountered on CT scans during lung cancer staging. METHODS: From April 2013 through July 2013, invitations were distributed to all members of the Fleischner Society, Society of Thoracic Radiology, General Thoracic Surgical Club, and the American Association of Bronchology and Interventional Pulmonology to participate in an anonymous online image-based and text-based 20-question survey regarding lymph node classification for lung cancer staging on CT imaging. RESULTS: Three hundred thirty-seven people responded (approximately 25% participation). Respondents consisted of self-reported thoracic radiologists (n = 158), thoracic surgeons (n = 102), and pulmonologists who perform endobronchial ultrasonography (n = 77). Half of the respondents (50%; 95% CI, 44%-55%) reported using the IASLC lymph node map in daily practice, with no significant differences between subspecialties. A disparity was observed between the IASLC definition sets and their interpretation and application on CT scans, in particular for lymph nodes near the thoracic inlet, anterior to the trachea, anterior to the tracheal bifurcation, near the ligamentum arteriosum, between the bronchus intermedius and esophagus, in the internal mammary space, and adjacent to the heart. CONCLUSIONS: Use of older lymph node maps and inconsistencies in interpretation and application of definitions in the IASLC lymph node map may potentially lead to misclassification of stage and suboptimal management of lung cancer in some patients.

Historical Evolution of Imaging Techniques for the Evaluation of Pulmonary Embolism.

As we celebrate the 100th anniversary of the founding of the Radiological Society of North America (RSNA), it seems fitting to look back at the major accomplishments of the radiology community in the diagnosis of pulmonary embolism. Few diseases have so consistently captured the attention of the medical community. Since the first description of pulmonary embolism by Virchow in the 1850s, clinicians have struggled to reach a timely diagnosis of this common condition because of its nonspecific and often confusing clinical picture. As imaging tests started to gain importance in the 1900s, the approach to diagnosing pulmonary embolism also began to change. Rapid improvements in angiography, ventilation-perfusion imaging, and cross-sectional imaging modalities such as computed tomography (CT) and magnetic resonance imaging have constantly forced health care professionals to rethink how they diagnose pulmonary embolism. Needless to say, the way pulmonary embolism is diagnosed today is distinctly different from how it was diagnosed in Virchow's era; and imaging, particularly CT, now forms the cornerstone of diagnostic evaluation. Currently, radiology offers a variety of tests that are fast and accurate and can provide anatomic and functional information, thus allowing early diagnosis and triage of cases. This review provides a historical journey into the evolution of these imaging tests and highlights some of the major breakthroughs achieved by the radiology community and RSNA in this process. Also highlighted are areas of ongoing research and development in this field of imaging as radiologists seek to combat some of the newer challenges faced by modern medicine, such as rising health care costs and radiation dose hazards.

Transcatheter structural cardiac intervention: a radiology perspective.

OBJECTIVE: Valvular heart disease continues to remain a significant cardiovascular problem worldwide. Imaging techniques, such as echocardiography, CT, and MRI have enabled development of newer transcatheter approaches for cardiovascular diseases. CONCLUSION: In this article, we discuss the commonly seen valvular diseases and various transcatheter valvular intervention techniques. We highlight the roles of CT and MRI in planning these procedures and discuss critical reporting information that needs to be conveyed to the interventionalists.

Building a bridge to save a failing ventricle: radiologic evaluation of short- and long-term cardiac assist devices.

Heart failure is recognized with increasing frequency worldwide and often progresses to an advanced refractory state. Although the reference standard for treatment of advanced heart failure remains cardiac transplantation, the increasing shortage of donor organs and the unsuitability of many patients for transplantation surgery has led to a search for alternative therapies. One such therapy is mechanical circulatory support, which helps relieve the load on the ventricle and thereby allows it to recover function. In addition, there is increasing evidence supporting the use of mechanical devices as a bridge to recovery in patients with acute refractory heart failure. In this article, the imaging evaluation of various commonly used short- and long-term cardiac assist devices is discussed, and their relevant mechanisms of action and physiology are described. Imaging, particularly computed tomography (CT), plays a crucial role in preoperative evaluation for assessment of candidacy for implantation of a left ventricular assist device (LVAD) or total artificial heart (TAH). Also, echocardiography and CT are indispensable in assessment of complications associated with cardiac devices. Complications commonly associated with short-term assist devices include bleeding and malpositioning, whereas long-term devices such as LVADs may be associated with infection, pump thrombosis, and cannula malfunction, as well as bleeding. CT is also commonly performed for preoperative planning before LVAD or TAH explantation, replacement of a device or one of its components, and cardiac transplantation. Online supplemental material is available for this article.

International association for the study of lung cancer (IASLC) lymph node map: radiologic review with CT illustration.

Accurate clinical or pretreatment stage classification of lung cancer leads to optimal treatment outcomes and improved prognostication. Such classification requires an accurate assessment of the clinical extent of regional lymph node metastasis. Consistent and reproducible regional lymph node designations facilitate reliable assessment of the clinical extent of regional lymph node metastasis. Regional lymph node maps, such as the Naruke lymph node map and the Mountain-Dresler modification of the American Thoracic Society lymph node map, were proposed for this purpose in the past. The most recent regional lymph node map to be published is the International Association for the Study of Lung Cancer (IASLC) lymph node map. The IASLC lymph node map supersedes all previous maps and should be used in tandem with the current seventh edition of the tumor, node, metastasis stage classification for lung cancer.

Clear vision through the haze: a practical approach to ground-glass opacity.

Ground-glass opacity (GGO) is a common, nonspecific imaging finding on chest computed tomography that may occur in a variety of pulmonary diseases. GGO may be the result of partial filling of alveolar spaces, thickening of the alveolar walls or septal interstitium, or a combination of partial filling of alveolar spaces and thickening of the alveolar walls and septal interstitium at the histopathologic level. Diseases that commonly manifest on chest computed tomography as GGO include pulmonary edema, alveolar hemorrhage, nonspecific interstitial pneumonia, hypersensitivity pneumonitis, and pulmonary alveolar proteinosis. Generating an extensive list of possible causes of GGO in radiologic reports would not be helpful to referring physicians. Preferably, a more concise and focused list of differential diagnostic possibilities may be constructed using a systematic approach to further classify GGO based on morphology, distribution, and ancillary imaging findings, such as the presence of cysts, traction bronchiectasis, and air trapping. Correlation with clinical history, such as the chronicity of symptoms, the patient's immune status, and preexisting medical conditions is vital. By thorough analysis of imaging patterns and consideration of relevant clinical information, the radiologist can generate a succinct and useful imaging differential diagnosis when confronted with the nonspecific finding of GGO.

Pertinent reportable incidental cardiac findings on chest CT without electrocardiography gating: review of 268 consecutive cases.

BACKGROUND: Pertinent reportable cardiac findings on non-electrocardiography (ECG)-gated chest CT examinations have become easier to detect given recent advancements in multidetector CT technology. However, those findings are easily overlooked on routine chest CT without ECG gating given residual inherent cardiac motion artifact and non-cardiac indications. PURPOSE: To describe and quantify the types of pertinent reportable cardiac findings that can be detected on chest CT examinations without ECG gating and evaluate how often they were reported. MATERIAL AND METHODS: Two radiologists retrospectively reviewed (blinded to the original interpretation) 268 consecutive routine adult chest CT examinations without ECG gating for the presence of pertinent reportable cardiac findings. Retrospective interpretations were then compared with the original radiological reports. RESULTS: One hundred and sixty-three patients (61%) had pertinent reportable cardiac findings. The findings encountered included: coronary artery disease (n = 131; 80.0%), coronary artery bypass grafts (n = 10; 6.1%), left ventricular aneurysm (n = 1; 0.6%), valve calcification (n = 131; 80.0%), valve repair/replacement (n = 5; 3.1%), pericardial effusion (n = 33; 20.2%), left atrial appendage thrombus (n = 1; 0.6%), cardiac mass (n = 1; 0.6%), and cardiac chamber enlargement (n = 29; 17.8%). On the original radiological reports 22.3% of the pertinent reportable cardiac findings, detected by the two radiologists retrospectively, were not reported. CONCLUSION: Detection of pertinent reportable cardiac findings on routine chest CT examinations without ECG gating is possible. The high volume of chest CT examinations without ECG gating represents an opportunity for radiologists to comment on the presence or absence of cardiac disease which may influence future clinical decisions.

Basics of cardiopulmonary bypass: normal and abnormal postoperative CT appearances.

Cardiothoracic surgical procedures with and without cardiopulmonary bypass are becoming more commonly performed as surgical techniques improve and the population ages. Changes related to cardiopulmonary bypass are often depicted at routine postoperative computed tomographic (CT) studies performed for various reasons. The purpose of this article is to present knowledge critical to the accurate postoperative evaluation of the patient who has undergone cardiopulmonary bypass. This article will review the surgical technique for cardiopulmonary bypass, as well as the associated normal and abnormal postoperative imaging findings. Common cannulation sites used for cardiopulmonary bypass include the ascending aorta, axillary artery, right atrium, superior vena cava, and inferior vena cava. Normal postoperative findings related to cardiopulmonary bypass include (a) felt pledgets, which are used to reinforce cannulation sites; (b) oversewn side grafts; and (c) oversewn graft side branches. These normal postoperative findings can be mistaken for abnormalities. Abnormal postoperative findings related to cardiopulmonary bypass include pseudoaneurysm formation at cannulation sites, aortic dissection, and seroma formation. An awareness of normal and abnormal postoperative CT findings related to cardiopulmonary bypass is critical for all radiologists who interpret chest CT studies, to help prevent unnecessary further evaluation and to help direct prompt treatment when warranted.

Mediastinal lymph node staging: from noninvasive to surgical.

OBJECTIVE: The purpose of this review is to describe the current lymph node stations and lymph node staging of non-small cell lung carcinoma. Minimally invasive and invasive methods of mediastinal lymph node staging are emphasized, and the relative accuracy and limitations of each modality are described. CONCLUSION: Lung carcinoma remains the most common cause of cancer death in the United States. Accurate staging of lung cancer is imperative for implementing the correct therapy and assessing patient prognosis.

Cardiac CT of non-shunt pathology of the interatrial septum.

The development and anatomy of the interatrial septum is complex. With the increasing use of cardiac CT and its precise delineation of the anatomy, it is important for the cardiac imager to become familiar with the normal anatomic structures that compose the interatrial septum and their variants. Furthermore, it is important to recognize pathologic processes occurring in this region other than atrial septal defects and potential imaging pitfalls. This pictorial essay provides a detailed review of these topics with emphasis in CT appearance and related technical aspects.