European Society of Radiology: Could you please give a detailed overview of when and for which diseases you use cardiac imaging?
Orly Goitein: Cardiac imaging utilising both CT and MRI has become the standard of care and an integral part of cardiovascular patient’s investigation. Cardiac CT (CCTA) offers superb anatomical coronary evaluation. Its high negative predictive value enables non-invasive coronary assessment at a relatively low radiation exposure. Indications for CCTA utilisation are constantly increasing. The NICE (National Institute for Health and Care Excellence) guidelines have recently addressed cardiac CT as the ‘first line’ test for chest pain evaluation. Other indications include ‘triple rule out’ for ruling out aortic dissection, pulmonary embolism and coronary disease. Post-coronary artery bypass surgery assessment allows graft patency demonstration as well as a graft to sternum anatomy in redo (re-operative) surgical cases. Thus, dictation the correct surgical approach in redo cases. CCTA offers a ‘one stop shop’ investigation prior to TAVI (transcatheter aortic valve implantation), including aortic annulus size, calcification and anatomy, procedure approach be it transfemoral or transapical and even rules out significant coronary stenosis.
Cardiac MRI (CMR) offers comprehensive cardiac evaluation including function, perfusion, flow and myocardial characterisation. CMR is considered the ‘gold standard’ for cardiac function quantification. Stress perfusion imaging (using either adenosine or dipyridamole) allows high spatial and temporal resolution in the demonstration of inducible perfusion defects. CMR is the only modality allowing myocardial characterisation, enabling the differentiation between ischaemic and non-ischaemic cardiomyopathy. Delayed enhancement and distinct pattern recognition offer a definition of specific non-ischaemic cardiomyopathies. Congenital heart disease utilises CMR routinely for cardiac function, shunt quantification, valve assessment and anatomical delineation.
Proper integration of both CCTA and CMR in the cardiology-imaging arsenal results in high-end professional, accurate reproducible and comprehensive evaluation.
ESR: Which modalities are usually used for what?
OG: Some of the common indications for CCTA include ruling out coronary artery disease, ventricular thrombus delineation, post-bypass graft evaluation and congenital heart disease.
CCTA offers structural assessment prior to pulmonary vein isolation, left atrial appendage occlusion insertion, mitral valve procedures and TAVI procedure.
ESR: What is the role of the radiologist within the ‘heart team’? How would you describe the cooperation between radiologists, cardiologists, and other physicians?
OG: The radiologist plays a central role in the ‘heart team’. During a discussion regarding complex cases, the radiologist can tailor specific protocols for the clinical question at hand. Thus, the proper scan using a dedicated specific protocol will yield the highest diagnostic quality for the case.
The cooperation among radiologists, cardiologists and other physicians should be guided by the best patient care. Since cardiac imaging is the issue in question, all participants should strive to cooperate in order to achieve the best combination of all imaging modalities and thus truly act as a multidisciplinary team.
ESR: Radiographers/radiological technologists are also part of the team. When and how do you interact with them?
OG: The radiological technologists and radiographers are an integral part of the cardiac imaging team. High professional performance, personal guidance, teaching and teamwork will result in the highest level of commitment from the entire cardiac imaging team.
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?
OG: I work in a large academic hospital. Cardiac imaging including CCTA and CMR are practised daily. There are three dedicated radiologists in our team and three dedicated cardiologists (one of which is a paediatric cardiologist). Cardiac imaging takes all of my time.
ESR: Do you have direct contact with patients and if yes, what is the nature of that contact?
OG: I seldom have contact with patients. Usually, I will consult the technologist to determine how to perform the scan. In problematic cases, I would join the team at the scanner and help either in tailoring and performing complex studies (CCTA and CMR), beta blocker administration (CCTA) etc.
ESR: If you had the means: what would you change in education, training and daily practice in cardiac imaging?
OG: I would expand physician education both within the hospital and in outpatient facilities (radiologists, cardiologists, internal medicine, and paediatricians) in order to further enhance the proper utilisation of advanced cardiac imaging.
ESR: What are the most recent advances in cardiac imaging and what significance do they have for improving healthcare?
OG: Recent advances include daily practice of parametric mapping further pushing the envelope in myocardial characterisation.
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?
OG: Since I started practising cardiac imaging 14 years ago, CCTA became a daily scan, taking less than 1 second and exposing the patient to 1–2 mSv on average. CCTA in congenital heart disease has been endorsed and integrated into neonatal and paediatric patient care. CMR has advanced significantly in myocardial characterisation including both delayed enhancement and parametric mapping. The spatial resolution of scans has improved significantly. Flow sequences including 4D flow are being implemented and will enhance the information CMR can provide in a short dedicated scan.
ESR: Is artificial intelligence already having an impact on cardiac imaging and how do you see that developing in the future?
OG: Artificial intelligence is not being used routinely, but I have no doubt it will be fully implemented once the technology has matured.
Dr. Orly Goitein is a cardiovascular radiologist and head of the cardiovascular imaging unit at the Radiology Department at Sheba Medical Centre in Tel Aviv, Israel, which is affiliated with the Sackler School of Medicine and Tel Aviv University.
She trained in Shaare Zedek Medical Center, Jerusalem, in general radiology and later at the University of Pittsburgh Medical Centre (UPMC) in the United States in cardiovascular imaging. Between 2004–2005 she acted as staff radiologists at UPMC.
Since 2001 she has been an active researcher in multimodality cardiac radiology, with a special interest in cardiac CT and cardiac MRI. Under her management, the diagnostic cardiovascular unit became the largest unit in Israel. Under her supervision over 3,000 CCTA scans and 2,000 CMR scans are performed yearly. Dr. Goitein is the author of 60 papers, one book chapter and more than 150 scientific posters and oral presentations. She is a member of the Society for Cardiovascular Magnetic Resonance (SCMR) publications committee. She organised three local meetings (cardiac imaging marathon) which hosted distinguished speakers in the field of cardiovascular imaging. Dr. Goitein serves as a member of the EACVI certification team.