Multi-institutional Protocol Guidance for Pediatric Photon-counting CT.

Performing CT in children comes with unique challenges such as greater degrees of patient motion, smaller and densely packed anatomy, and potential risks of radiation exposure. The technical advancements of photon-counting detector (PCD) CT enable decreased radiation dose and noise, as well as increased spatial and contrast resolution across all ages, compared with conventional energy-integrating detector CT. It is therefore valuable to review the relevant technical aspects and principles specific to protocol development on the new PCD CT platform to realize the potential benefits for this population. The purpose of this article, based on multi-institutional clinical and research experience from pediatric radiologists and medical physicists, is to provide protocol guidance for use of PCD CT in the imaging of pediatric patients.

Recurrent medical imaging exposures for the care of patients: one way forward.

Medical imaging is both valuable and essential in the care of patients. Much of this imaging depends on ionizing radiation with attendant responsibilities for judicious use when performing an examination. This responsibility applies in settings of both individual as well as multiple (recurrent) imaging with associated repeated radiation exposures. In addressing the roles and responsibilities of the medical communities in the paradigm of recurrent imaging, both the International Atomic Energy Agency (IAEA) and the American Association of Physicists in Medicine (AAPM) have issued position statements, each affirmed by other organizations. The apparent difference in focus and approach has resulted in a lack of clarity and continued debate. Aiming towards a coherent approach in dealing with radiation exposure in recurrent imaging, the IAEA convened a panel of experts, the purpose of which was to identify common ground and reconcile divergent perspectives. The effort has led to clarifying recommendations for radiation exposure aspects of recurrent imaging, including the relevance of patient agency and the provider-patient covenant in clinical decision-making. CLINICAL RELEVANCE STATEMENT: An increasing awareness, generating some lack of clarity and divergence in perspectives, with patients receiving relatively high radiation doses (e.g., ≥ 100 mSv) from recurrent imaging warrants a multi-stakeholder accord for the benefit of patients, providers, and the imaging community. KEY POINTS: • Recurrent medical imaging can result in an accumulation of exposures which exceeds 100 milli Sieverts. • Professional organizations have different perspectives on roles and responsibilities for recurrent imaging. • An expert panel reconciles differing perspectives for addressing radiation exposure from recurrent medical imaging.

Proposed Priorities for Low-Dose Radiation Research and Their Relevance to the Practice of Radiology.

Because ionizing radiation is widely used in medical imaging and in military, industry, and commercial applications, programmatic management and advancement in knowledge is needed, especially related to the health effects of low-dose radiation. The U.S. Congress in partnership with the U.S. Department of Energy called on the National Academies of Sciences, Engineering, and Medicine (NASEM) to develop a long-term strategic and prioritized agenda for low-dose radiation research. Low doses were defined as dose amounts less than 100 mGy or low-dose rates less than 5 mGy per hour. The 2022 NASEM report was divided into sections detailing the low-dose radiation exposure and health effects, scientific basis for radiation protection, status of low-dose radiation research, a prioritized radiation research agenda, and essential components of a low-dose radiation research program, including resources needed and recommendations for financial recourse. The purpose of this review is to summarize this report and examine the recommendations to assess how these pertain to the practice of radiology and medicine.

Comparison of the different imaging modalities used to image pediatric oncology patients: A COG diagnostic imaging committee/SPR oncology committee white paper.

Diagnostic imaging is essential in the diagnosis and management, including surveillance, of known or suspected cancer in children. The independent and combined roles of the various modalities, consisting of radiography, fluoroscopy, ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), and nuclear medicine (NM), are both prescribed through protocols but also function in caring for complications that may occur during or subsequent to treatment such as infection, bleeding, or organ compromise. Use of a specific imaging modality may be based on situational circumstances such as a brain CT or MR for a new onset seizure, chest CT for respiratory signs or symptoms, or US for gross hematuria. However, in many situations, there are competing choices that do not easily lend themselves to a formulaic approach as options; these situations depend on the contributions of a variety of factors based on a combination of the clinical scenario and the strengths and limitations of the imaging modalities. Therefore, an improved understanding of the potential influence of the imaging decision pathways in pediatric cancer care can come from comparison among the individual diagnostic imaging modalities. The purpose of the following material to is to provide such a comparison. To do this, pediatric imaging content experts for the individual modalities of radiography and fluoroscopy, US, CT, MRI, and NM will discuss the individual modality strengths and limitations.

Pediatric Applications of Photon-Counting Detector CT.

Photon-counting detector (PCD) CT represents the most recent generational advance in CT technology. PCD CT has the potential to reduce image noise, improve spatial resolution and contrast resolution, and provide multispectral capability, all of which may be achieved with an overall decrease in the radiation dose. These effects may be used to reduce the iodinated contrast media dose and potentially obtain multiphase images through a single-acquisition technique. The benefits of PCD CT have previously been shown primarily in phantoms and adult patients. This article describes the application of PCD CT in children, as illustrated by clinical examples from a commercially available PCD CT system.

Thyroid Nodules on Ultrasound in Children and Young Adults: Comparison of Diagnostic Performance of Radiologists' Impressions, ACR TI-RADS, and a Deep Learning Algorithm.

BACKGROUND. In current clinical practice, thyroid nodules in children are generally evaluated on the basis of radiologists' overall impressions of ultrasound images. OBJECTIVE. The purpose of this article is to compare the diagnostic performance of radiologists' overall impression, the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS), and a deep learning algorithm in differentiating benign and malignant thyroid nodules on ultrasound in children and young adults. METHODS. This retrospective study included 139 patients (median age 17.5 years; 119 female patients, 20 male patients) evaluated from January 1, 2004, to September 18, 2020, who were 21 years old and younger with a thyroid nodule on ultrasound with definitive pathologic results from fine-needle aspiration and/or surgical excision to serve as the reference standard. A single nodule per patient was selected, and one transverse and one longitudinal image each of the nodules were extracted for further evaluation. Three radiologists independently characterized nodules on the basis of their overall impression (benign vs malignant) and ACR TI-RADS. A previously developed deep learning algorithm determined for each nodule a likelihood of malignancy, which was used to derive a risk level. Sensitivities and specificities for malignancy were calculated. Agreement was assessed using Cohen kappa coefficients. RESULTS. For radiologists' overall impression, sensitivity ranged from 32.1% to 75.0% (mean, 58.3%; 95% CI, 49.2-67.3%), and specificity ranged from 63.8% to 93.9% (mean, 79.9%; 95% CI, 73.8-85.7%). For ACR TI-RADS, sensitivity ranged from 82.1% to 87.5% (mean, 85.1%; 95% CI, 77.3-92.1%), and specificity ranged from 47.0% to 54.2% (mean, 50.6%; 95% CI, 41.4-59.8%). The deep learning algorithm had a sensitivity of 87.5% (95% CI, 78.3-95.5%) and specificity of 36.1% (95% CI, 25.6-46.8%). Interobserver agreement among pairwise combinations of readers, expressed as kappa, for overall impression was 0.227-0.472 and for ACR TI-RADS was 0.597-0.643. CONCLUSION. Both ACR TI-RADS and the deep learning algorithm had higher sensitivity albeit lower specificity compared with overall impressions. The deep learning algorithm had similar sensitivity but lower specificity than ACR TI-RADS. Interobserver agreement was higher for ACR TI-RADS than for overall impressions. CLINICAL IMPACT. ACR TI-RADS and the deep learning algorithm may serve as potential alternative strategies for guiding decisions to perform fine-needle aspiration of thyroid nodules in children.

Imaging of Right Lower Quadrant Pain in Children and Adolescents: AJR Expert Panel Narrative Review.

Right lower quadrant (RLQ) pain is a common clinical presentation in children, and accurate clinical diagnosis remains challenging given that this nonspecific presentation is associated with numerous surgical and nonsurgical conditions. The broad differential diagnosis varies by patient age and sex. Important considerations in the selection of a diagnostic imaging strategy include the sequencing, performance, and cost of tests. This article provides a comprehensive narrative review of the diagnostic imaging of RLQ pain in children and adolescents, including a discussion of the complementary roles of ultrasound, CT, and MRI; description of key imaging findings based on available evidence; and presentation of salient differential diagnoses. Subspecialized pediatric emergency medicine and surgical perspectives are also provided as further clinical insight into this common, but often challenging, scenario. Finally, the current status of imaging of RLQ pain in children and adolescents is summarized on the basis of expert consensus.

U.S. Diagnostic Reference Levels and Achievable Doses for 10 Pediatric CT Examinations.

Background Diagnostic reference levels (DRLs) and achievable doses (ADs) were developed for the 10 most commonly performed pediatric CT examinations in the United States using the American College of Radiology Dose Index Registry. Purpose To develop robust, current, national DRLs and ADs for the 10 most commonly performed pediatric CT examinations as a function of patient age and size. Materials and Methods Data on 10 pediatric (ie, patients aged 18 years and younger) CT examinations performed between 2016 and 2020 at 1625 facilities were analyzed. For head and neck examinations, dose indexes were analyzed based on patient age; for body examinations, dose indexes were analyzed for patient age and effective diameter. Data from 1 543 535 examinations provided medians for AD and 75th percentiles for DRLs for volume CT dose index (CTDIvol), dose-length product (DLP), and size-specific dose estimate (SSDE). Results Of all facilities analyzed, 66% of the facilities (1068 of 1625) were community hospitals, 16% (264 of 1625) were freestanding centers, 9.5% (154 of 1625) were academic facilities, and 3.5% (57 of 1625) were dedicated children's hospitals. Fifty-two percent of the patients (798 577 of 1 543 535) were boys, and 48% (744 958 of 1 543 535) were girls. The median age of patients was 14 years (boys, 13 years; girls, 15 years). The head was the most frequent anatomy examined with CT (876 655 of 1 543 535 examinations [57%]). For head without contrast material CT examinations, the age-based CTDIvol AD ranged from 19 to 46 mGy, and DRL ranged from 23 to 55 mGy, with both AD and DRL increasing with age. For body examinations, DRLs and ADs for size-based CTDIvol, SSDE, and DLP increased consistently with the patient's effective diameter. Conclusion Diagnostic reference levels and achievable doses as a function of patient age and effective diameter were developed for the 10 most commonly performed CT pediatric examinations using American College of Radiology Dose Index Registry data. These benchmarks can guide CT facilities in adjusting pediatric CT protocols and resultant doses for their patients. © RSNA, 2021 An earlier incorrect version appeared online. This article was corrected on October 29, 2021.

Medical workforce in the United States.

This section focuses on the professional workforce comprised of the primary medical specialties that utilize ionizing radiation in their practices. Those discussed include the specialties of radiology and radiation oncology, as well as the subspecialties of radiology, namely diagnostic radiology, interventional radiology, nuclear radiology, and nuclear medicine. These professionals provide essential health care services, for example, the interpretation of imaging studies, the provision of interventional procedures, radionuclide therapeutic treatments, and radiation therapy. In addition, they may be called on to function as part of a radiologic emergency response team to care for potentially exposed persons following radiation events, for example, detonation of a nuclear weapon, nuclear power plant accidents, and transportation incidents. For these reasons, maintenance of an adequate workforce in each of these professions is essential to meeting the nation's future needs. Currently, there is a shortage for all physicians in the medical radiology workforce.

Increasing the Utilization of Moderate Sedation Services for Pediatric Imaging.

Performing motion-free imaging is frequently challenging in children. To bridge the gap between examinations performed in children who are awake and in those under general anesthesia, a moderate sedation program was implemented at our institution but was seldom used despite substantial eligibility. In conjunction with a 5-month quality improvement (QI) course, a multidisciplinary team was assembled and, by using an A3 approach, sought to address the most important key drivers of low utilization, namely the need for clear moderate sedation eligibility criteria, reliable protocol routing order, consistent moderate sedation screening performed by registered nurses (RNs), and enhanced visibility of moderate sedation services to ordering providers. Initial steps focused on developing better-defined criteria and protocoling standard work for technologists and RNs, with coaching and audits. Modality-specific forecasting was then implemented to reroute profiles of patients who were awaiting scheduling or already scheduled for an examination with general anesthesia to the moderate sedation queue to identify more eligible patients. These manual efforts were coupled with higher reliability but more protracted electronic health record changes, facilitating automated protocol routing on the basis of moderate sedation eligibility and order entry constraints. As a result, scheduled imaging examinations requiring moderate sedation increased from a mean of 1.2 examinations per week to a sustained 6.1 examinations per week (range, 4-8) over the 5-month period, exceeding the team SMART (specific, measurable, achievable, relevant, and time bound) goal to achieve an average of five examinations per week by the QI course end. By targeting the most high-impact yet modifiable process deficiencies through a multifaceted team approach and initially investing in manual efforts to gain cultural buy-in while awaiting higher-reliability interventions, the project achieved success and may serve as a more general model for workflow change when there is organizational resistance. ©RSNA, 2021.

Radiation use in diagnostic imaging in children: approaching the value of the pediatric radiology community.

Medical imaging is foundational in the care of children, and much of the medical imaging province depends on ionizing radiation: radiography, fluoroscopy, CT and nuclear imaging. Many considerations for this imaging in children are distinct in the domains of appropriate radiation use, other factors that determine examination quality, the opportunities to engage and educate through networking, and the translation of research efforts. Given these needs, it is worth approaching the contributions and their impact by the pediatric radiology community, especially to the enhancement of this value in the care of children.

Clinical concordance with Image Gently guidelines for pediatric computed tomography: a study across 663,417 CT scans at 53 clinical facilities.

BACKGROUND: Managing patient radiation dose in pediatric computed tomography (CT) examinations is essential. Some organizations, most notably Image Gently, have suggested techniques to lower dose to pediatric patients and mitigate risk while maintaining image quality. OBJECTIVE: We sought to validate whether institutions are observing Image Gently guidelines in practice. MATERIALS AND METHODS: Dose-relevant data from 663,417 abdomen-pelvis and chest CT scans were obtained from 53 facilities. Patients were assigned arbitrary age cohorts with a minimum size of n=12 patients in each age group, for statistical purposes. All pediatric (<19 years old) cohorts at a given facility were compared to the adult cohort by a Kruskal-Wallis test for each of the four scan parameters - (1) x-ray tube kilovoltage (kV), (2) tube-current-by-exposure-time product (tube mAs), (3) scan pitch and (4) tube rotation time - to assess whether the distribution of values in the pediatric cohorts differed from the adult cohort. The same was repeated with volume CT dose index (CTDIvol) and size-specific dose estimate (SSDE) to assess whether pediatric cohorts received less dose than adult cohorts. A P-value of <0.05 was deemed significant. RESULTS: Across the 150 pediatric cohorts, 134 had scan parameters that were more child-sized than their adult counterparts. In 128 of these 134 pediatric cohorts, the CTDIvol was less than the adult counterpart. In 111 of these 128 pediatric cohorts, the SSDE was less than the adult counterpart. CONCLUSION: The study reaffirms that in practice, Image Gently's suggestions of lowering tube mAs and peak kilovoltage are commonly employed and effective at reducing pediatric CT dose.

Patient Exposure from Radiologic and Nuclear Medicine Procedures in the United States: Procedure Volume and Effective Dose for the Period 2006-2016.

Background Comprehensive assessments of the frequency and associated doses from radiologic and nuclear medicine procedures are rarely conducted. The use of these procedures and the population-based radiation dose increased remarkably from 1980 to 2006. Purpose To determine the change in per capita radiation exposure in the United States from 2006 to 2016. Materials and Methods The U.S. National Council on Radiation Protection and Measurements conducted a retrospective assessment for 2016 and compared the results to previously published data for the year 2006. Effective dose values for procedures were obtained from the literature, and frequency data were obtained from commercial, governmental, and professional society data. Results In the United States in 2006, an estimated 377 million diagnostic and interventional radiologic examinations were performed. This value remained essentially the same for 2016 even though the U.S. population had increased by about 24 million people. The number of CT scans performed increased from 67 million to 84 million, but the number of other procedures (eg, diagnostic fluoroscopy) and nuclear medicine procedures decreased from 17 million to 13.5 million. The number of dental radiographic and dental CT examinations performed was estimated to be about 320 million in 2016. Using the tissue-weighting factors from Publication 60 of the International Commission on Radiological Protection, the U.S. annual individual (per capita) effective dose from diagnostic and interventional medical procedures was estimated to have been 2.9 mSv in 2006 and 2.3 mSv in 2016, with the collective doses being 885 000 and 755 000 person-sievert, respectively. Conclusion The trend from 1980 to 2006 of increasing dose from medical radiation has reversed. Estimated 2016 total collective effective dose and radiation dose per capita dose are lower than in 2006. © RSNA, 2020 See also the editorial by Einstein in this issue.

Bone manifestations in neuronopathic Gaucher disease while receiving high-dose enzyme replacement therapy.

Avascular necrosis (AVN), one type of bone infarction, is a major irreversible complication of Gaucher disease (GD). In this report, two pediatric patients with GD type 3, homozygous for the L483P pathogenic variant (formerly L444P), developed AVN despite treatment on long-term, high-dose enzyme replacement therapy (ERT). ERT was initiated in both patients, who had intact spleens, shortly after diagnosis with an initial dramatic response. However, both patients exhibited AVN after 5.5 and 11 years on high-dose ERT, respectively, despite good compliance and normalized hematological findings and visceral symptoms. This report demonstrates the importance of careful, regular surveillance of the musculoskeletal system in addition to monitoring the neurological symptoms associated with neuronopathic GD. Additionally, it highlights the limitations of ERT in terms of targeting certain sanctuary sites such as bone marrow and suggests the need for new treatment modalities other than ERT monotherapy to address these limitations.

Expanding the Concept of Diagnostic Reference Levels to Noise and Dose Reference Levels in CT.

OBJECTIVE. Diagnostic reference levels were developed as guidance for radiation dose in medical imaging and, by inference, diagnostic quality. The objective of this work was to expand the concept of diagnostic reference levels to explicitly include noise of CT examinations to simultaneously target both dose and quality through corresponding reference values. MATERIALS AND METHODS. The study consisted of 2851 adult CT examinations performed with scanners from two manufacturers and two clinical protocols: abdominopelvic CT with IV contrast administration and chest CT without IV contrast administration. An institutional informatics system was used to automatically extract protocol type, patient diameter, volume CT dose index, and noise magnitude from images. The data were divided into five reference patient size ranges. Noise reference level, noise reference range, dose reference level, and dose reference range were defined for each size range. RESULTS. The data exhibited strong dependence between dose and patient size, weak dependence between noise and patient size, and different trends for different manufacturers with differing strategies for tube current modulation. The results suggest size-based reference intervals and levels for noise and dose (e.g., noise reference level and noise reference range of 11.5-12.9 HU and 11.0-14.0 HU for chest CT and 10.1-12.1 HU and 9.4-13.7 HU for abdominopelvic CT examinations) that can be targeted to improve clinical performance consistency. CONCLUSION. New reference levels and ranges, which simultaneously consider image noise and radiation dose information across wide patient populations, were defined and determined for two clinical protocols. The methods of new quantitative constraints may provide unique and useful information about the goal of managing the variability of image quality and dose in clinical CT examinations.

Neuroimaging findings in infantile Pompe patients treated with enzyme replacement therapy.

BACKGROUND: Recombinant human acid α-glucosidase (rhGAA) enzyme replacement therapy (ERT) has prolonged survival in infantile Pompe disease (IPD), but has unmasked central nervous system (CNS) changes. METHODS: Brain imaging, consisting of computed tomography (CT) and/or magnetic resonance imaging (MRI), was performed on 23 patients with IPD (17 CRIM-positive, 6 CRIM-negative) aged 2-38months. Most patients had baseline neuroimaging performed prior to the initiation of ERT. Follow-up neuroimaging was performed in eight. RESULTS: Sixteen patients (70%) had neuroimaging abnormalities consisting of ventricular enlargement (VE) and/or extra-axial cerebrospinal fluid accumulation (EACSF) at baseline, with delayed myelination in two. Follow-up neuroimaging (n=8) after 6-153months showed marked improvement, with normalization of VE and EACSF in seven patients. Two of three patients imaged after age 10years demonstrated white matter changes, with one noted to have a basilar artery aneurysm. CONCLUSIONS: Mild abnormalities on brain imaging in untreated or newly treated patients with IPD tend to resolve with time, in conjunction with ERT. However, white matter changes are emerging as seen in Patients 1 and 3 which included abnormal periventricular white matter changes with subtle signal abnormalities in the basal ganglia and minimal, symmetric signal abnormalities involving the deep frontoparietal cerebral white matter, respectively. The role of neuroimaging as part of the clinical evaluation of IPD needs to be considered to assess for white matter changes and cerebral aneurysms.

Using the American College of Radiology Dose Index Registry to Evaluate Practice Patterns and Radiation Dose Estimates of Pediatric Body CT.

OBJECTIVE: Imaging registries afford opportunities to study large, heterogeneous populations. The purpose of this study was to examine the American College of Radiology CT Dose Index Registry (DIR) for dose-related demographics and metrics of common pediatric body CT examinations. MATERIALS AND METHODS: Single-phase CT examinations of the abdomen and pelvis and chest submitted to the DIR over a 5-year period (July 2011-June 2016) were evaluated (head CT frequency was also collected). CT examinations were stratified into five age groups, and examination frequency was determined across age and sex. Standard dose indexes (volume CT dose index, dose-length product, and size-specific dose estimate) were categorized by body part and age. Contributions to the DIR were also categorized by region and practice type. RESULTS: Over the study period 411,655 single-phase pediatric examinations of the abdomen and pelvis, chest, and head, constituting 5.7% of the total (adult and pediatric) examinations, were submitted to the DIR. Head CT was the most common examination across all age groups. The majority of all scan types were performed for patients in the second decade of life. Dose increased for all scan types as age increased; the dose for abdominopelvic CT was the highest in each age group. Even though the DIR was queried for single-phase examinations only, as many as 32.4% of studies contained multiple irradiation events. When these additional scans were included, the volume CT dose index for each scan type increased. Among the studies in the DIR, 99.8% came from institutions within the United States. Community practices and those that specialize in pediatrics were nearly equally represented. CONCLUSION: The DIR provides valuable information about practice patterns and dose trends for pediatric CT and may assist in establishing diagnostic reference levels in the pediatric population.

Current utilization and procedural practices in pediatric whole-body MRI.

BACKGROUND: Whole-body magnetic resonance imaging (MRI) is an evolving and increasingly powerful imaging tool with a variety of applications in the pediatric patient population. Variability exists among radiology practices in how this MRI tool is used and how it is performed. OBJECTIVE: Our objective was to gain an improved understanding of technical and utilization practices in pediatric whole-body MRI across North America by exploring indications for exam performance, determining referral patterns, and assessing technical protocols and procedures. MATERIALS AND METHODS: A 19-question survey was generated in Survey Monkey and distributed in 2016 to the Society for Pediatric Radiology membership. The survey asked questions that included practice type, imaging modality preferences for diseases commonly evaluated with whole-body MRI, MRI field strength and sequence selection, and billing practices. RESULTS: Data were obtained from 62 unique responses to the survey, representing 471 physicians. The majority (93%) practice in an academic institution or private practice with academic affiliation and most practices have utilized whole-body MRI for less than 6 years. Whole-body MRI is performed in pediatric patients 0 to 18 years of age, and was the preferred imaging modality for diagnosis/staging/follow-up in neurofibromatosis, type 1 (75%), chronic recurrent multifocal osteomyelitis (CRMO) (74%), cancer predisposition syndromes (75%), vasculopathies (50%) and disseminated/multifocal infection (49%). The most commonly utilized sequences are coronal short tau inversion recovery (STIR) (90%), coronal T1 with or without fat saturation (65%), and axial diffusion-weighted imaging (DWI) (48%). No preference was shown for either 1.5-T or 3-T systems. Wide variability was seen in preference for billing code utilization, though the majority use chest/abdomen/pelvis (57%) or unlisted MRI (37%) codes. CONCLUSION: Radiology practitioners - represented by the Society for Pediatric Radiology pediatric radiologists - are using whole-body MRI in the imaging care of pediatric patients for a variety of indications. Survey results reveal some variability in exam utilization and technical performance practices among those pediatric radiologists who perform whole-body MRI.

Radiation dose management for pediatric cardiac computed tomography: a report from the Image Gently 'Have-A-Heart' campaign.

Children with congenital or acquired heart disease can be exposed to relatively high lifetime cumulative doses of ionizing radiation from necessary medical imaging procedures including radiography, fluoroscopic procedures including diagnostic and interventional cardiac catheterizations, electrophysiology examinations, cardiac computed tomography (CT) studies, and nuclear cardiology examinations. Despite the clinical necessity of these imaging studies, the related ionizing radiation exposure could pose an increased lifetime attributable cancer risk. The Image Gently "Have-A-Heart" campaign is promoting the appropriate use of medical imaging studies in children with congenital or acquired heart disease while minimizing radiation exposure. The focus of this manuscript is to provide a comprehensive review of radiation dose management and CT performance in children with congenital or acquired heart disease.