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.

Summary of the 2022 ACR Intersociety Meeting.

The ACR Intersociety Committee meeting of 2022 (ISC-2022) was convened around the theme of "Recovering From The Great Resignation, Moral Injury and Other Stressors: Rebuilding Radiology for a Robust Future." Representatives from 29 radiology organizations, including all radiology subspecialties, radiation oncology, and medical physics, as well as academic and private practice radiologists, met for 3 days in early August in Park City, Utah, to search for solutions to the most pressing problems facing the specialty of radiology in 2022. Of these, the mismatch between the clinical workload and the available radiologist workforce was foremost-as many other identifiable problems flowed downstream from this, including high job turnover, lack of time for teaching and research, radiologist burnout, and moral injury.

ACR Appropriateness Criteria® Suspected Pulmonary Embolism: 2022 Update.

Pulmonary embolism (PE) remains a common and important clinical condition that cannot be accurately diagnosed on the basis of signs, symptoms, and history alone. The diagnosis of PE has been facilitated by technical advancements and multidetector CT pulmonary angiography, which is the major diagnostic modality currently used. Ventilation and perfusion scans remain largely accurate and useful in certain settings. MR angiography can be useful in some clinical scenarios and lower-extremity ultrasound can substitute by demonstrating deep vein thrombosis; however, if negative, further studies to exclude PE are indicated. In all cases, correlation with the clinical status, particularly with risk factors, improves not only the accuracy of diagnostic imaging but also overall utilization. Other diagnostic tests have limited roles. The ACR 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 in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Nonischemic Myocardial Disease with Clinical Manifestations (Ischemic Cardiomyopathy Already Excluded).

Nonischemic cardiomyopathies encompass a broad spectrum of myocardial disorders with mechanical or electrical dysfunction without evidence of ischemia. There are five broad variants of nonischemic cardiomyopathies; hypertrophic cardiomyopathy (Variant 1), restrictive or infiltrative cardiomyopathy (Variant 2), dilated or unclassified cardiomyopathy (Variant 3), arrhythmogenic cardiomyopathy (Variant 4), and inflammatory cardiomyopathy (Variant 5). For variants 1, 3, and 4, resting transthoracic echocardiography, MRI heart function and morphology without and with contrast, and MRI heart function and morphology without contrast are the usually appropriate imaging modalities. For variants 2 and 5, resting transthoracic echocardiography and MRI heart function and morphology without and with contrast are the usually appropriate imaging modalities. 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.

Statement from the North American Society for Cardiovascular Imaging on imaging strategies to reduce the scarcity of healthcare resources during the COVID-19 outbreak.

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is an evolving global pandemic that is predicted to strain healthcare resources at multiple locations throughout North America and the World. As of April 6, 2020, the apex of infection rates is predicted to occur within 1 to 5 weeks at various locations. Widespread reports of personal protective equipment (PPE) shortages, and healthcare worker exposure to disease have become commonplace. To mitigate this crisis, we are suggesting imaging strategies that aim to use the least PPE, require the smallest number of potential staff exposures, and streamlines utilization of imaging. They are broadly organized by (1) substituting a noninvasive diagnostic test in place of a semi-invasive or invasive diagnostic tests, and (2) consolidating diagnostic imaging.

ACR Appropriateness Criteria® Chest Pain-Possible Acute Coronary Syndrome.

Chest pain is a frequent cause for emergency department visits and inpatient evaluation, with particular concern for acute coronary syndrome as an etiology, since cardiovascular disease is the leading cause of death in the United States. Although history-based, electrocardiographic, and laboratory evaluations have shown promise in identifying coronary artery disease, early accurate diagnosis is paramount and there is an important role for imaging examinations to determine the presence and extent of anatomic coronary abnormality and ischemic physiology, to guide management with regard to optimal medical therapy or revascularization, and ultimately to thereby improve patient outcomes. A summary of the various methods for initial imaging evaluation of suspected acute coronary syndrome is outlined in this document. 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.

Primary Neuroendocrine Tumor of the Thymus: Radiological and Pathological Correlation.

Primary neuroendocrine tumors of the thymus are extremely rare. In this report, we describe a case of a 69 year-old man with an intermediate grade thymic neuroendocrine tumor. The radiologic and histopathologic features of thymic neuroendocrine tumors are discussed with reference to relevant literature.

Computed Tomography of Cardiac Valves: Review.

Valvular heart disease is a common clinical problem. Although echocardiography is the standard technique for the noninvasive evaluation of the valves, cardiac CT has evolved to become a useful tool in the evaluation of the cardiac structures as well. Importantly, CT allows for improved quantification of valvular calcification due to its superior spatial resolution. It may improve the detection of small valvular or perivalvular pathology or the characterization of valvular masses and vegetations. This review describes the assessment of normal and diseased heart valves by cardiac CT and discusses its strengths and weaknesses.

ACR Appropriateness Criteria® Chronic Chest Pain-Noncardiac Etiology Unlikely-Low to Intermediate Probability of Coronary Artery Disease.

Chronic chest pain (CCP) of a cardiac etiology is a common clinical problem. The diagnosis and classification of the case of chest pain has rapidly evolved providing the clinician with multiple cardiac imaging strategies. Though scintigraphy and rest echocardiography remain as appropriate imaging tools in the diagnostic evaluation, new technology is available. Current evidence supports the use of alternative imaging tests such as coronary computed tomography angiography (CCTA), cardiac MRI (CMRI), or Rb-82 PET/CT. Since multiple imaging modalities are available to the clinician, the most appropriate noninvasive imaging strategy will be based upon the patient's clinical presentation and clinical status. 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.

ACR Appropriateness Criteria® Suspected New-Onset and Known Nonacute Heart Failure.

While there is no single diagnostic test for heart failure (HF), imaging plays a supportive role beginning with confirmation of HF, especially by detecting ventricular dysfunction (Variant 1). Ejection fraction (EF) is important in HF classification, and imaging plays a subsequent role in differentiation between HF with reduced EF (HFrEF) versus preserved EF (HFpEF) (Variant 2). Once HFrEF is identified, distinction between ischemic and nonischemic etiologies with imaging support (Variant 3) facilitates further planning. Imaging approaches which are usually appropriate include: both resting transthoracic echocardiography (TTE) and chest radiography for Variant 1; resting TTE and/or MRI (including functional, without absolute need for contrast) for Variant 2; and for Variant 3, a. Coronary CTA or coronary arteriography (if high pretest probability/symptoms for ischemic disease) for coronary assessment; b. Rest/vasodilator stress SPECT/CT, PET/CT, or MRI for myocardial perfusion assessment; c. Rest/exercise or inotropic stress TTE for myocardial contraction assessment; or d. MRI (including morphologic with contrast) for myocardial characterization. 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.

ACR Appropriateness Criteria® Imaging for Transcatheter Aortic Valve Replacement.

Aortic stenosis is a common valvular condition with increasing prevalence in aging populations. When severe and symptomatic, the downstream prognosis is poor without surgical or transcatheter aortic valve replacement. Transcatheter aortic valve replacement is now considered a viable alternative to surgical aortic valve replacement in patients considered high and intermediate risk for surgery. Pre-intervention imaging with echocardiography and CT are essential for procedure planning and device selection to help optimize clinical outcomes with MR angiography playing largely a complementary role. Modern 3-D cross-sectional imaging has consistently shown to help reduce procedural complications from vascular access injury to paravalvular regurgitation and coronary obstruction. 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.

ACR Appropriateness Criteria® Dyspnea-Suspected Cardiac Origin.

This article discusses imaging guidelines for five dyspnea variants: (1) dyspnea due to heart failure, ischemia not excluded; (2) dyspnea due to suspected nonischemic heart failure, ischemia excluded; (3) dyspnea due to suspected valvular heart disease, ischemia excluded; (4) dyspnea due to suspected cardiac arrhythmia, ischemia excluded; and (5) dyspnea due to suspected pericardial disease, ischemia excluded. 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.

ACR Appropriateness Criteria® Acute Chest Pain-Suspected Pulmonary Embolism.

Pulmonary embolism (PE) remains a common and important clinical condition that cannot be accurately diagnosed on the basis of signs, symptoms, and history alone. The diagnosis of PE has been facilitated by technical advancements and multidetector CT pulmonary angiography, which is the major diagnostic modality currently used. Ventilation and perfusion scans remain largely accurate and useful in certain settings. Lower-extremity ultrasound can substitute by demonstrating deep vein thrombosis; however, if negative, further studies to exclude PE are indicated. In all cases, correlation with the clinical status, particularly with risk factors, improves not only the accuracy of diagnostic imaging but also overall utilization. Other diagnostic tests have limited roles. 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.

Palpitations and a Left Ventricular Mass: An Odd Presentation of Left Dominant Arrhythmogenic Cardiomyopathy.

A 20-year-old woman presented with palpitations. Echocardiography demonstrated a left ventricular mass involving the posterolateral apical wall and protruding into the ventricular cavity. Evaluation with magnetic resonance imaging (MRI) suggested fatty consistency with all edges well defined except the medial, which was ill defined, raising concern for an invasive liposarcoma. Open core needle biopsy demonstrated mature adipocytes infiltrating the myocardium with extensive interstitial fibrosis. The diagnosis was left-dominant arrhythmogenic cardiomyopathy. Two-year MRI follow-up demonstrates no change in size. This case illustrates the use and limits of cardiac MRI and the value of open cardiac biopsy in diagnosis.

National trends among radiologists in reporting coronary artery calcium in non-gated chest computed tomography.

Coronary artery calcification (CAC) is a known risk factor for adverse outcomes in the general population and in patients with coronary artery disease. We performed a survey of United States radiologists to evaluate the trends in reporting the presence or absence of CAC on NCCT examinations. An 11 multiple-choice questionnaire was distributed to members of the American College of Radiology, and 530 members participated in the study. Eighty-seven percent of the analyzed group report the presence of CAC on standard CT scans of the chest, and approximately half them (52 %) use a qualitative modifier. Only 32 % of cardiac imagers were aware of the published data correlating qualitative and quantitative calcium scores on non-gated chest CT examinations compared to 17 % of non-cardiac imagers. We believe that subjective or objective grading of coronary calcified plaque burden on standard chest CT exams is warranted as it may not only help risk-stratify patients, but also may eliminate the need for dedicated CACS in many patients and may be useful in treatment guidance.

Coronary-Pulmonary Artery Fistulas: A Systematic Review.

PURPOSE: Coronary-pulmonary arterial fistulas (CPAFs) are rare coronary artery anomalies that have been described only in limited case reports. This study aims to evaluate the clinical presentation and imaging findings of CPAFs collected from 6 participating medical centers along with CPAFs reported in the literature, to discern any general trends present in CPAFs. MATERIALS AND METHODS: A total of 25 cases of CPAF diagnosed by coronary computed tomography angiography were collected across 6 participating institutions. In addition, utilizing a PubMed literature search, 78 additional CPAF cases were obtained. The imaging findings and relevant clinical history were reviewed. RESULTS: Of the 103 CPAF patients, 60 (63% of patients with sex known) were male, with ages ranging from newborn to 88 years (mean=46.1 y). The most common symptoms reported were chest pain (n=40, 39%) and dyspnea (n=26, 25%), with a murmur as the most common physical examination finding (n=38, 37%). The most common coronary artery of origin for a CPAF was the left main/left anterior descending (n=87, 84%), followed by the right coronary artery (n=39, 38%). The fistula most commonly terminated in the main pulmonary artery (n=92, 89%). Multiple CPAFs were present in 46 cases (45%). Coronary artery aneurysms were identified in 20 cases (19%). Pediatric CPAF cases were usually associated with pulmonary atresia with ventricular septal defect. CONCLUSIONS: CPAFs are seen in a variety of clinical settings, from infants with advanced congenital heart disease to elderly patients who have undergone revascularization surgery. Although coronary artery fistulas have previously been described as rarely involving multiple coronary arteries, with the right coronary artery being most often involved, our series demonstrates that multiple fistulas are commonly present, with the most common pattern being between the left main/left anterior descending and the main pulmonary trunk.

Evaluation of left ventricular function using volumetric computed tomography in the clinical setting.

OBJECTIVE: To correlate the left ventricular parameters obtained with 64-slice Volumetric Computed Tomography (VCT) with those obtained with the reference standard, cardiovascular magnetic resonance (CMR) imaging. METHODS: VCT and a 3.0T MRI scanner were used. Results from both studies were independently evaluated by two cardiologists. A linear correlation and a paired Student's t test were used to analyze the data with a P<0.05 being considered significant. RESULTS: Thirty consecutive patients were evaluated with VCT and CMR. The left ventricular indices for CMR and VCT were, respectively, mass 86.4±25.8 vs. 82.7±27.6g (P=0.31); ESV 45.5±27.8 vs. 48.7±40.4ml (P=.405); EDV 101.3±32.7 vs. 105.1±44.0ml (P=0.475); SV 55.9±16.1 vs. 56.8±15.6ml (P=0.713); LVEF 57.5±13.2% vs. 56.9±12.4% (P=0.630). No differences in intraobserver variability for both methods were found, CT r=0.96, r(2)=0.92 P<0.0001 and MR r=0.96 r(2)=0.93 P<0.0001. There was no significant statistical difference in the presence of artifacts. CONCLUSION: There is a close correlation between CMRI and VCT in the evaluation of LV function. VCT is as useful as 3T CMR, and could be incorporated as another resource for evaluating LV function.

Interventricular membranous septal aneurysm: CT and MR manifestations.

Advanced cardiac imaging is a valuable method to investigate cardiac malformations. The detection of the interventricular membranous septum has clinical significance due to thrombogenic and arrythmogenic predisposition, as well as a role in obstructing the pulmonary flow. This review describes six clinical presentations in which advanced cardiac imaging has been the tool for evaluation, with special emphasis in CT angiography and cardiac MRI sequences. Teaching Points • The interventricular membranous septum can predispose patients to thrombogenic and arrythmogenic events. • Subpulmonic stenosis relates to the protrusion of the aneurysm into the right ventricle • During surgery, ventricular pressures of the opened heart become balanced, making the aneurysm less evident.

Case 223: Arytenoid Dislocation.

A 71-year-old man with a history of atrial fibrillation refractory to medical therapy and lung cancer status after left upper lobectomy presented to our hospital for elective cardioversion and rate control with tikosyn. Overnight, the patient became unresponsive and was found to be in a state of cardiogenic shock. A code was called, and he was stabilized after cardioversion and bedside intubation. His stay in the intensive care unit was complicated by ventilator-associated pneumonia. The patient subsequently underwent multiple failed extubation attempts, requiring two additional reintubations. He was finally extubated 18 days after his initial admission to the intensive care unit. After he was discharged, he reported a hoarse voice and was only able to whisper. His voice varied in timbre and volume, and it became hoarser with use. Otolaryngology evaluation, including laryngoscopy and video stroboscopy, showed immobility of the right vocal cord. He was referred for speech therapy, and a computed tomographic (CT) examination of the neck was ordered.