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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">During the last decade there have been marked improvements in computed tomography &#40;CT&#41; scanner technology&#46; The first clinical CT scanners had limited use for cardiac applications&#44; mainly due to poor spatial and temporal resolution&#44; and also because of long scan times&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> Current-generation multidetector CT &#40;MDCT&#41; scanners are characterized by rapid coverage of large anatomic volumes&#44; with high spatial and temporal resolution and lower radiation doses&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1&#44;2</span></a> These recent developments have noticeably widened the cardiac applications of CT and made it an important tool in the assessment of congenital heart disease &#40;CHD&#41; in children&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">CHD is the most commonly occurring type of congenital anomaly&#44; affecting 8-10&#47;1000 live births&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1&#44;4</span></a> These are complex and challenging patients who often have residual hemodynamic lesions requiring repeated interventions throughout life&#44; and therefore require close surveillance&#46; Transthoracic echocardiography &#40;TTE&#41; is well established as the first-line imaging technique for assessment of CHD&#44; due to its non-invasive nature and ability to detail cardiac morphology and function&#44; and is both portable and widely available&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1&#44;5</span></a> However&#44; TTE is operator-dependent&#44; has a limited acoustic window and has several limitations in the visualization of complex anomalies involving extracardiac structures&#44; particularly the coronary arteries and great vessels&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> As patients with CHD have a wide spectrum of morphologic variations&#44; detailed and accurate information regarding the anatomy involved is crucial for preoperative planning&#46; Advanced imaging techniques such as magnetic resonance imaging &#40;MRI&#41; and cardiac computed tomography angiography &#40;CCTA&#41; are therefore being more widely used as complementary techniques to TTE&#44; in a multimodality imaging approach&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1&#44;6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Cardiac MRI enables functional as well as morphologic assessment of complex CHD&#44; and has multiplanar capability with a wide field of view&#44; and no requirement for ionizing radiation&#46; Compared with MRI&#44; CCTA has the advantages of its ability to visualize intracardiac and extracardiac structures &#40;including the airways and lung parenchyma&#41;&#44; higher spatial resolution and much shorter scanning times &#40;5-10 minutes&#41;&#44; and for these reasons requires less sedation&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Newer-generation dual-source CT scanners offer the advantage of submillimeter isotropic spatial resolution&#44; and data acquisition requires only a part of the cardiac cycle or at most a few cardiac cycles&#46; Prospectively ECG-triggered high-pitch scan mode or volumetric target mode provide full anatomic coverage of a pediatric thorax in less than a second or a single heartbeat&#44; reducing both respiratory and cardiac motion&#46; The higher spatial and temporal resolution combined with rapid image acquisition provide images of small cardiovascular structures&#44; like coronary arteries&#44; conduits&#44; baffles&#44; and the anatomy of the thoracic arterial and venous vasculature with high diagnostic accuracy&#44; even at high heart rates&#46; This rapid image acquisition also reduces or eliminates the need for sedation or anesthesia in small children who are unable to cooperate with a short breath hold&#44; while still providing good image quality&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1&#44;6&#44;7</span></a> On top of this&#44; the prospectively ECG-triggered high-pitch spiral mode provided by second-generation dual-source CT technology&#44; with a high pitch of 3&#46;4 and fast table speed of 460 mm&#47;s&#44; can substantially decrease radiation doses because of its fast&#44; non-overlapping spiral data acquisition&#46; Recent studies have shown that prospectively ECG-triggered high-pitch mode is feasible in children with CHD&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a> This is of paramount importance because&#44; despite these strengths&#44; ionizing radiation exposure associated with CCTA is still one of the main limitations of the use of this technique at pediatric ages&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">5&#44;7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">All imaging modalities that use radiation must adhere to the &#8216;as low as reasonably achievable&#8217; &#40;ALARA&#41; concept regarding the radiation dose delivered by the exam&#46; This principle is even more important in the pediatric population&#46; It is generally acknowledged that radiation dose is more concerning for a pediatric than an adult patient due to a relative increase in radiation sensitivity and a longer life span during which adverse effects may manifest clinically&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> Moreover&#44; there are concerns about the number of imaging examinations that a child with CHD will undergo throughout life&#44; due to the risk of radiation-induced chromosome damage caused by cumulative radiation&#44; with increased lifetime risk of malignancy&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">3&#44;5&#44;7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Considerable efforts have therefore been made to develop CT technology in order to substantially reduce radiation exposure&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a> Several dose-saving strategies are in routine clinical use in pediatric CT&#44; especially for neonates and young children&#44; including body size-adaptive CT protocols&#44; reduced tube voltage&#44; tube current modulation and prospective ECG triggering as mentioned above&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> If other factors are kept constant&#44; decreasing the tube voltage from 120 to 80 kVp can by itself result in up to 65&#37; dose reduction&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> In infants and children&#44; tube potential should be reduced to 70 or 80 kVp when performing cardiac CT&#46; Many teenagers and young adults can be imaged with 80 kVp as well&#44; reserving 100 kVp for muscular or mild to moderately overweight patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">6&#44;8</span></a> Automatic tube current modulation selects the lowest possible tube current &#40;mAs&#41; for a given tube potential &#40;kV&#41;&#44; maintaining fairly constant image noise throughout the exam by varying mAs based on tissue attenuation&#46; This software can reduce radiation doses by up to 40-50&#37; over standardized imaging algorithms&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> However&#44; these aggressive radiation dose reduction protocols could lead to degraded image quality due to higher susceptibility to beam-hardening artifacts and increased image noise because of low photon flux&#46; The use of advanced iterative reconstruction techniques results in improved image quality&#44; primarily by reducing image noise&#44; and allows further dose reduction without compromising diagnostic image accuracy&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In their article published in the current issue of the <span class="elsevierStyleItalic">Journal</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a> &#214;zt&#252;rk and colleagues explore recent advances in CT technology and how these have widened the cardiac applications of CT&#44; highlighting the role of latest-generation MDCT scanners as another tool for the assessment of CHD in pediatric patients&#46; CCTA exams were performed with a 320-row MDCT scanner&#44; and a low radiation dose protocol was used&#46; Tube current was adjusted to the patient&#39;s weight and a tube voltage of 80 kV was used for patients weighing less than 20 kg&#46; The same tube voltage could have been used with patients up to 50-60 kg&#44; further lowering the radiation exposure in these cases&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> The authors conclude that intracardiac malformations and cardiovascular connection anomalies were more accurately determined by TTE than by CCTA&#44; while there was no significant difference between these two techniques in predicting great vessel malformations&#46; This latter finding is not consistent with other studies in the literature that found MDCT angiography to be more effective than TTE in visualizing extracardiac vascular structures&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">3&#44;10&#8211;12</span></a> The authors performed CT scans without ECG gating&#44; which may partially explain these findings&#46; Prospectively ECG-triggered scan mode improves image quality and diagnostic accuracy&#44; and allows lower radiation exposure&#46; Although decreasing the tube voltage and tube current can effectively reduce the dose of radiation received by the patient&#44; the level of radiation exposure in children can remain high in the absence of prospective ECG gating&#46; The authors also highlight the importance of the experience and knowledge required to perform high-quality CT scans in pediatric patients with CHD&#46; The imaging physician needs to be actively involved in directing patient preparation and establishing the image acquisition protocol&#44; which has to be tailored to the individualized patient&#46; The interpretation and reporting of CHD CT scans is time-consuming and demands expertise that combines the skills and knowledge of both radiology and pediatric cardiology&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the current era&#44; a non-invasive multimodality imaging approach to the patient with CHD is crucial to better planning of invasive procedures&#46; With the advent of new-generation scanners using fast sequences with higher spatial and temporal resolution and aggressive radiation dose reduction techniques&#44; allowing scan radiation doses lower than 1 mSv and maintaining diagnostic image accuracy&#44; cardiovascular CT is increasingly being used in the pediatric population as an adjunct to echocardiography when cardiac MRI is considered high risk&#44; contraindicated&#44; or unlikely to provide the answer to the clinical question&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">So&#44; now we can &#8230; apply the latest CT technology to selected pediatric CHD patients&#44; in order to improve their clinical management and outcomes&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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New-generation multidetector computed tomography technology for the management of congenital heart disease in children: Now we can!
Avanços tecnológicos da tomografia computorizada multicorte e sua aplicação no manejo das cardiopatias congénitas em idade pediátrica: agora podemos!
Marta António
Serviço de Cardiologia Pediátrica, Hospital de Santa Marta, Centro Hospitalar e Universitário de Lisboa Central, Lisboa, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">During the last decade there have been marked improvements in computed tomography &#40;CT&#41; scanner technology&#46; The first clinical CT scanners had limited use for cardiac applications&#44; mainly due to poor spatial and temporal resolution&#44; and also because of long scan times&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> Current-generation multidetector CT &#40;MDCT&#41; scanners are characterized by rapid coverage of large anatomic volumes&#44; with high spatial and temporal resolution and lower radiation doses&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1&#44;2</span></a> These recent developments have noticeably widened the cardiac applications of CT and made it an important tool in the assessment of congenital heart disease &#40;CHD&#41; in children&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">CHD is the most commonly occurring type of congenital anomaly&#44; affecting 8-10&#47;1000 live births&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1&#44;4</span></a> These are complex and challenging patients who often have residual hemodynamic lesions requiring repeated interventions throughout life&#44; and therefore require close surveillance&#46; Transthoracic echocardiography &#40;TTE&#41; is well established as the first-line imaging technique for assessment of CHD&#44; due to its non-invasive nature and ability to detail cardiac morphology and function&#44; and is both portable and widely available&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1&#44;5</span></a> However&#44; TTE is operator-dependent&#44; has a limited acoustic window and has several limitations in the visualization of complex anomalies involving extracardiac structures&#44; particularly the coronary arteries and great vessels&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> As patients with CHD have a wide spectrum of morphologic variations&#44; detailed and accurate information regarding the anatomy involved is crucial for preoperative planning&#46; Advanced imaging techniques such as magnetic resonance imaging &#40;MRI&#41; and cardiac computed tomography angiography &#40;CCTA&#41; are therefore being more widely used as complementary techniques to TTE&#44; in a multimodality imaging approach&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1&#44;6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Cardiac MRI enables functional as well as morphologic assessment of complex CHD&#44; and has multiplanar capability with a wide field of view&#44; and no requirement for ionizing radiation&#46; Compared with MRI&#44; CCTA has the advantages of its ability to visualize intracardiac and extracardiac structures &#40;including the airways and lung parenchyma&#41;&#44; higher spatial resolution and much shorter scanning times &#40;5-10 minutes&#41;&#44; and for these reasons requires less sedation&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Newer-generation dual-source CT scanners offer the advantage of submillimeter isotropic spatial resolution&#44; and data acquisition requires only a part of the cardiac cycle or at most a few cardiac cycles&#46; Prospectively ECG-triggered high-pitch scan mode or volumetric target mode provide full anatomic coverage of a pediatric thorax in less than a second or a single heartbeat&#44; reducing both respiratory and cardiac motion&#46; The higher spatial and temporal resolution combined with rapid image acquisition provide images of small cardiovascular structures&#44; like coronary arteries&#44; conduits&#44; baffles&#44; and the anatomy of the thoracic arterial and venous vasculature with high diagnostic accuracy&#44; even at high heart rates&#46; This rapid image acquisition also reduces or eliminates the need for sedation or anesthesia in small children who are unable to cooperate with a short breath hold&#44; while still providing good image quality&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1&#44;6&#44;7</span></a> On top of this&#44; the prospectively ECG-triggered high-pitch spiral mode provided by second-generation dual-source CT technology&#44; with a high pitch of 3&#46;4 and fast table speed of 460 mm&#47;s&#44; can substantially decrease radiation doses because of its fast&#44; non-overlapping spiral data acquisition&#46; Recent studies have shown that prospectively ECG-triggered high-pitch mode is feasible in children with CHD&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a> This is of paramount importance because&#44; despite these strengths&#44; ionizing radiation exposure associated with CCTA is still one of the main limitations of the use of this technique at pediatric ages&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">5&#44;7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">All imaging modalities that use radiation must adhere to the &#8216;as low as reasonably achievable&#8217; &#40;ALARA&#41; concept regarding the radiation dose delivered by the exam&#46; This principle is even more important in the pediatric population&#46; It is generally acknowledged that radiation dose is more concerning for a pediatric than an adult patient due to a relative increase in radiation sensitivity and a longer life span during which adverse effects may manifest clinically&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> Moreover&#44; there are concerns about the number of imaging examinations that a child with CHD will undergo throughout life&#44; due to the risk of radiation-induced chromosome damage caused by cumulative radiation&#44; with increased lifetime risk of malignancy&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">3&#44;5&#44;7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Considerable efforts have therefore been made to develop CT technology in order to substantially reduce radiation exposure&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a> Several dose-saving strategies are in routine clinical use in pediatric CT&#44; especially for neonates and young children&#44; including body size-adaptive CT protocols&#44; reduced tube voltage&#44; tube current modulation and prospective ECG triggering as mentioned above&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> If other factors are kept constant&#44; decreasing the tube voltage from 120 to 80 kVp can by itself result in up to 65&#37; dose reduction&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> In infants and children&#44; tube potential should be reduced to 70 or 80 kVp when performing cardiac CT&#46; Many teenagers and young adults can be imaged with 80 kVp as well&#44; reserving 100 kVp for muscular or mild to moderately overweight patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">6&#44;8</span></a> Automatic tube current modulation selects the lowest possible tube current &#40;mAs&#41; for a given tube potential &#40;kV&#41;&#44; maintaining fairly constant image noise throughout the exam by varying mAs based on tissue attenuation&#46; This software can reduce radiation doses by up to 40-50&#37; over standardized imaging algorithms&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> However&#44; these aggressive radiation dose reduction protocols could lead to degraded image quality due to higher susceptibility to beam-hardening artifacts and increased image noise because of low photon flux&#46; The use of advanced iterative reconstruction techniques results in improved image quality&#44; primarily by reducing image noise&#44; and allows further dose reduction without compromising diagnostic image accuracy&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In their article published in the current issue of the <span class="elsevierStyleItalic">Journal</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a> &#214;zt&#252;rk and colleagues explore recent advances in CT technology and how these have widened the cardiac applications of CT&#44; highlighting the role of latest-generation MDCT scanners as another tool for the assessment of CHD in pediatric patients&#46; CCTA exams were performed with a 320-row MDCT scanner&#44; and a low radiation dose protocol was used&#46; Tube current was adjusted to the patient&#39;s weight and a tube voltage of 80 kV was used for patients weighing less than 20 kg&#46; The same tube voltage could have been used with patients up to 50-60 kg&#44; further lowering the radiation exposure in these cases&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> The authors conclude that intracardiac malformations and cardiovascular connection anomalies were more accurately determined by TTE than by CCTA&#44; while there was no significant difference between these two techniques in predicting great vessel malformations&#46; This latter finding is not consistent with other studies in the literature that found MDCT angiography to be more effective than TTE in visualizing extracardiac vascular structures&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">3&#44;10&#8211;12</span></a> The authors performed CT scans without ECG gating&#44; which may partially explain these findings&#46; Prospectively ECG-triggered scan mode improves image quality and diagnostic accuracy&#44; and allows lower radiation exposure&#46; Although decreasing the tube voltage and tube current can effectively reduce the dose of radiation received by the patient&#44; the level of radiation exposure in children can remain high in the absence of prospective ECG gating&#46; The authors also highlight the importance of the experience and knowledge required to perform high-quality CT scans in pediatric patients with CHD&#46; The imaging physician needs to be actively involved in directing patient preparation and establishing the image acquisition protocol&#44; which has to be tailored to the individualized patient&#46; The interpretation and reporting of CHD CT scans is time-consuming and demands expertise that combines the skills and knowledge of both radiology and pediatric cardiology&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the current era&#44; a non-invasive multimodality imaging approach to the patient with CHD is crucial to better planning of invasive procedures&#46; With the advent of new-generation scanners using fast sequences with higher spatial and temporal resolution and aggressive radiation dose reduction techniques&#44; allowing scan radiation doses lower than 1 mSv and maintaining diagnostic image accuracy&#44; cardiovascular CT is increasingly being used in the pediatric population as an adjunct to echocardiography when cardiac MRI is considered high risk&#44; contraindicated&#44; or unlikely to provide the answer to the clinical question&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">So&#44; now we can &#8230; apply the latest CT technology to selected pediatric CHD patients&#44; in order to improve their clinical management and outcomes&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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