European Society of Radiology: Could you please give a detailed overview of when and for which diseases you use cardiac imaging?
Antanas Jankauskas: In the Lithuanian University of Health Sciences hospital we perform cardiac imaging studies to confirm or reject diagnosis of CAD, specify the haemodynamic significance of known stenosis, clarify congenital heart diseases and carry out myocardial pathology before interventional or surgical procedures. Indications, variety and amount of the cardiac and cardiovascular studies are increasingly expanding. The leading indication in our institution is suspected CAD, accounting for more than 700 CT coronary angiography studies annually. Approximately 400 cardiac MR studies were performed for various indications. I think that currently, interventional procedures of structural heart diseases is one of the most promising and challenging areas, where imaging procedures play a crucial role. I am very happy that our hospital is also working in this field, in fact, mitral and tricuspid valve implantation studies are ongoing in our centre.
ESR: Which modalities are usually used for what?
AJ: For suspected CAD we perform a coronary CT angiography, mainly for low and intermediate probability patients, also in selected cases we perform triple rule out studies. CT is mainly used to get high-quality angiographic studies – in addition to coronary CT, angiography is applied for pulmonary venous anatomy, congenital heart, great and peripheral vessels diseases.
MRI studies are mainly performed for morphologic and functional evaluation of myocardial, valvular pathology. Suspected cardiomyopathy, post ischaemic scar visualisation, right ventricle pathology, specification of valve function, clarification of suspected defects, arteriovenous shunts, aortic and peripheral artery MR angiography are the main indications for cardiac MRI in our hospital.
Rest and stress SPECT CT is routinely performed for haemodynamic significance of intermediate stenosis in our institution, less frequently it is clarified by functional 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?
AJ: I think that the heart team is an important part of clinical practice. A multidisciplinary approach has already proved its benefits by avoiding delayed diagnosis or inappropriate treatment in many clinical situations. On the other hand, it requires time and a certain level of expertise of team members. The main additive value of a radiologist in a heart team is when complex clinical situations are discussed, especially with additional findings, which is quite often the case.
ESR: Radiographers/radiological technologists are also part of the team. When and how do you interact with them?
AJ: In cardiac studies, qualified support of radiological technicians is the most important thing. This type of studies requires very intense collaboration between physicians and technicians because of many different clinical situations. Heart rate lowering preparation and scan protocol’s modification according to a patient’s anatomical properties and heart rate characteristics is achieved by a successfully functioning team. In our hospital, we communicate with radiographers directly and every particular specific clinical situation is clarified by discussing it.
Good image quality is essential in CT or MR angiographic studies in order to make a correct diagnosis. The continuous training and improvement of working skills is supported in our institution, which helps effectively communicate and collaborate in daily practice.
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?
AJ: In our institution, currently we are four radiologists, specialising in cardiac CT and/or MR studies. Also, there are four cardiologists working with us on the team. Such collaboration benefits both sides and especially benefits patients since many decisions are made by discussion and consensus.
Cardiac imaging takes almost half of my workload, the rest of the time I am engaged as general radiologist in various other areas, with the main emphasis on thoracic, urgent radiology. Also, the training of students and residents is part of my scientific activities.
ESR: Do you have direct contact with patients and if yes, what is the nature of that contact?
AJ: The direct contact with patients, compared to other medical specialties, is less practised in radiology. Before cardiac CT we mainly communicate with the patient about possible contraindications for heart rate lowering preparation. Also, some patients who are very worried about their health status, get informed directly about the results of the study. But this is not routine practice due to high workload.
ESR: If you had the means: what would you change in education, training and daily practice in cardiac imaging?
AJ: This field of radiology is very dynamic and rapidly changing – technological improvements result in an expansion of indications and increase the number of studies. Moreover, the collaboration with cardiologists is very intense, so we should keep a very high level of proficiency in order to be equivalent and useful partners. Education and training are very important and should be more standardised. I think that ESR should establish certain levels of cardiovascular radiology in order to motivate specialists to improve their knowledge.
ESR: What are the most recent advances in cardiac imaging and what significance do they have for improving healthcare?
AJ: Because my main field of interest is cardiovascular CT, I am really excited about the possibilities of introducing fractional flow reserve (FFR) CT technology. Because of this option, it is now possible to perform a one-stop-shop study, avoiding additional stress testing for patients with intermediate coronary stenosis, saving both time and costs. Also, iterative and model-based reconstruction algorithms are very important for saving patients radiation dose and contrast media, because coronary CT has the potential to be established as a reliable screening tool.
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?
AJ: I started my clinical practice with a 16-slice CT scanner. The acquisition lasted often more than 20 seconds, motion artefacts were a common quality degrading factor. Now we have a 320-slice scanner, which enables one beat scan, covering the entire heart. The radiation dose is often less than 1 mSv, and the image quality is very good.
Currently, there are identified certain features of plaque, which has a high risk of rupture. I believe that CT will further improve their robustness to identify vulnerable plaques. Increasing sensitivity of CT detectors and refinement of reconstruction algorithms will potentiate further radiation dose savings. Also, there is no doubt that the temporal resolution of CT scanners will increase and high heart rate patients will not be an issue for this study.
ESR: Is artificial intelligence already having an impact on cardiac imaging and how do you see that developing in the future?
AJ: Artificial intelligence has the potential to replace humans in many areas. Radiology and cardiac imaging is not an exception. In my opinion, if the process is not too rapid, this would be the most optimal scenario. In this case, advantages of artificial intelligence would be completely used and drawbacks counterbalanced. I think that artificial intelligence will not take over our workplaces, but it will increase the workflow of radiologists and decrease study costs. Thereby, the number of radiology studies will grow, which is a positive factor, especially in preventive medicine. Cardiac imaging, and especially CT angiography, has particular potential in this area. Also, we should further practise our creativity and scientific sense in order to work with artificial intelligence in a well-structured team, but not as competitors.
Assoc. Prof. Antanas Jankauskas is a cardiovascular radiologist and chairman of the cardiovascular radiology section at LUHS Kaunas Clinics in Kaunas, Lithuania, and board member of the Lithuanian Association of Radiologists. His main clinical and research interests are cardiac CT and MR; he defended his doctoral thesis in the field of coronary CT angiography. He is author or co-author of 15 peer-reviewed papers and 3 book chapters, as well as lecturer at national and international congresses, tutorials and refresher courses.