1 Hidayatullah Hamidi, Tariq Alam, Najibullah Rasouly, Sahar MaroofChoosing appropriate imaging modalities in pediatric congenital cardiovascular anomalies Hidayatullah Hamidi, Tariq Alam, Najibullah Rasouly, Sahar Maroof Radiology Department, FMIC, Kabul, AFG 5th FMIC international conference 2015 Introduction Congenital cardiovascular anomalies (CCVAs) remain considerable health problem in pediatric population. It may present as a sole abnormality of stenosis, obstruction, defect or connection problems or as a complex combination of these features. Radiology plays an important role in initial detection of CCVAs as well as in evaluation of post treatment conditions. Imaging can give structural and functional information about cardiovascular system, help to plan management, evaluate the results of intervention and predict longtime outcomes. Today various imaging modalities are utilized in detection and follow up of congenital cardiovascular anomalies and the trend in choosing the appropriate imaging modality is towards obtaining: more accurate morphological and/or functional information with non/less invasive techniques and reduced/no radiation exposure. Chest radiograph It is still the most important and most frequently performed radiological examination but with development of modern imaging techniques, its role in evaluation of CCVAs has largely been relegated to only of historical and academic interest, however it can give valuable information and narrow the differential diagnosis to few likely conditions. Echocardiography This non-invasive, portable, radiation free, widely availability and unexpansive modality with high resolution anatomical and functional information about cardiovascular system is the first line imaging technique. Its Major limitations are: limited acoustic window, operator dependence, poorer spatial resolution, inappropriate for evaluation of extra-cardiac lesions, coronary arteries, quantitative assessments of valvular dysfunction, ventricular volumetrics, and myocardial masses. Cardiovascular MR Imaging (cMRI) This radiation free and non invasive technique gives both anatomic and hemodynamic information. The common clinical indications for cMRI in neonates and infants are: investigation of thoracic vasculature in complex CCVAs, quantification of ventricular volumes, Follow-up after surgery or intervention and evaluation of primary cardiac tumors. Need for anaesthesia, less availability, higher cost and longer examination time are its disadvantages Objectives To develop an appropriate and organized practice of choosing first line imaging modalities as well as further imaging strategies among referring physicians, cardiologists, and radiologists in order to perform the most appropriate examinations in pediatric patients with suspected/diagnosed simple or complex congenital cardiovascular abnormalities according to patient's clinical situation and treatment planning considering the feasibility, sensitivity, specificity, safety and availability of these imaging modalities. A general diagnostic algorithm for evaluation of CCVAs according to patient’s clinical context, primary imaging findings and subsequent specific diagnostic questions. Cardiac catheterization: Currently reserved for hemodynamic assessment, in cases with pulmonary hypertension and complex Congenital cardiovascular diseases and in whom interventional treatment is necessary. Nuclear Scintigraphy It is used in selected circumstances. PET can be used to evaluate myocardial viability and metabolism. Method This article is based on review of several up to date published articles on cardiac imaging. References Ntsinjana, Hopewell N., Marina L. Hughes, and Andrew M. Taylor. "The role of cardiovascular magnetic resonance in pediatric congenital heart disease." J Cardiovasc Magn Reson 13.1 (2011): Baert, A. L. Radiological imaging of the neonatal chest. Ed. Veronica B. Donoghue. Springer Science & Business Media, 2010. Crean, Andrew. "Cardiovascular MR and CT in congenital heart disease." Heart93.12 (2007): Goo, Hyun Woo, et al. "CT of Congenital Heart Disease: Normal Anatomy and Typical Pathologic Conditions 1." Radiographics 23.suppl_1 (2003): S147-S165. Hoffman JIE, Kaplan S: The incidence of congenital heart disease. J Am Coll Cardiol 2002, 39: Ayush Goel and Dr Frank Gaillard et al: Congenital heart disease - chest x-ray approach, Siripornpitak, Suvipaporn, et al. "Cardiac CT angiography in children with congenital heart disease." European journal of radiology 82.7 (2013): Prakash, Ashwin, Andrew J. Powell, Tal Geva. "Multimodality noninvasive imaging for assessment of congenital heart disease." Circulation: Cardiovascular Imaging 3.1 (2010): Ferguson, Emma C., et al. "Classic imaging signs of congenital cardiovascular abnormalities." Radiographics 27.5 (2007): Al-Azzazy, Mohamad Zakaryia, Mohamad Sanad Nasr, and Mohamad A. Shoura. "Multidetector computed tomography (MDCT) angiography of thoracic aortic coarctation in pediatric patients: Pre-operative evaluation." The Egyptian Journal of Radiology and Nuclear Medicine 45.1 (2014): Kutty, Shelby, and David A. Danford. "Pediatric and Adult Congenital Heart Disease Imaging Choices and Considerations." Journal of Ultrasound in Medicine 32.8 (2013): Tsai, I-Chen, et al. "Neonatal cardiac multidetector row CT: why and how we do it." Pediatric radiology 38.4 (2008): Dillman, Jonathan R., and Ramiro J. Hernandez. "Role of CT in the evaluation of congenital cardiovascular disease in children." American Journal of Roentgenology (2009): Krishnamurthy R. Neonatal cardiac imaging. Pediatr Radiol 2010;40(4):518–27. Kellenberger, Christian J., Shi-Joon Yoo, and Emanuela R. Valsangiacomo Büchel. "Cardiovascular MR Imaging in Neonates and Infants with Congenital Heart Disease 1." Radiographics 27.1 (2007): 5-18. Simpson JM, Moore P, Teitel DF. Cardiac catheterization of low-birth-weight infants. Am J Cardiol 2001;87(12):1372–7 Bailliard F, Hughes ML, Taylor AM. Introduction to cardiac imaging in infants and children: techniques, potential, and role in the imaging work-up of various cardiac malformations and other pediatric heart conditions. Eur J Radiol 2008; 68(2):191–8. MDCT Angiography in a 75 days old girl diagnosed as TAPVR Type 1 with an ASD (a & b): Left sided vertical vein draining to left brachiocephalic vein and subsequently into the SVC (c): ASD (d) :Prominent pulmonary veins draining to vertical vein posterior to heart. b Cardiac CT Angiography (cCTA) Non-ECG gated cCTA is used for evaluation of extra cardiac lesions while ECG-gated cCTA is used for evaluation of coronary artery. The important issue regarding cCTA is the radiation exposure and the trend is how to keep the radiation dose as low as reasonably practicable (ALARP) with the balance of adequately interpretable image quality. b p Left: Chest radiograph obtained in an infant with a right-sided aortic arch Right: The same image with a superimposed drawing shows the characteristic boot-shaped sign produced by upturning of the cardiac apex because of right ventricular hypertrophy and by the concavity of the main pulmonary artery. DX: Tetralogy of Fallot Echo, cMRI and histologic features of myocardial rhabdomyoma.