Sarah Gubara, PhD (Host): This is Transformational Pediatrics with Children's Mercy, Kansas City. I am your host, Dr. Sarah Gubara. Today we have a panel discussion for the exciting Flash scanner and I invite you to listen in as we discuss.

Joining me today is Dr. Sanket Shah, Medical Director of Echocardiography and Co-Director of Non-Invasive Imaging at Children's Mercy and Dr. Erin Opfer, Vice Chair of Radiology and Section Chief of Cardiac Imaging at Children's Mercy. Hello and welcome.

Sanket Shah, MD, MHS, FAAP: Thank you, Dr. Gubara for having us.

Erin Opfer, DO: Hello.

Host: I'm so excited to talk to you about some of this innovative imaging. Dr. Opfer, what problems were existing beforehand that the new Flash scanner protocols solved, and how did they change clinical practice compared to earlier imaging technology?

Erin Opfer, DO: So with our new Flash scanner, it offers us benefits that the older dual source scanner, which we had, did not give us, in regards to lower radiation exposure, with the new photon and flash modes, and ability to do some of the scans without the use of sedation. So, it really has helped us in some populations to be able to scan faster, without as much need for sedation and less radiation.

 So we still can get all the same imaging that we used to get in the past, but, in a little bit, safer way and faster.

Host: That sounds incredible. So Dr. Shah, what are some of the primary applications of using this innovative technology in pediatric cardiology and how is it different from traditional cardiac imaging technology?

Sanket Shah, MD, MHS, FAAP: So, CT scan has, and the new Flash scanner has revolutionized the imaging in congenital heart disease in pediatric cardiology. We find it extremely valuable in our most challenging patients, which we call our single ventricle group of cardiology patients, where, one of the two pumping chambers or ventricles is very hypoplastic or small and not able to do the job. And we have to do a series of surgeries or interventions to make the circulation work.

Our group, recently presented this data at the Radiology Society in North America educational exhibit on how we have used this in each step of the way for the single ventricle surgical palliations, and optimized care and outcomes. It has led to quicker diagnostics and improved outcomes, and in especially in this population. It has also improved our imaging for neonates and other infants where we are able to do the scans without anesthesia or breath holds. So, it has been very patient friendly and gentle imaging and, and still very diagnostic and highly accurate with the resolution of less than half a millimeter.

Host: That sounds like a wonderful balance to better improve health outcomes and be better for patient experience as well. Dr. Opfer, do you see this technology changing how often Flash scanners are chosen over other imaging modalities?

Erin Opfer, DO: When we say Flash scanner, it's one mode that the scanner can do. Really what we're talking most about is the photon counting, which is a different way to scan than the conventional CTs. So the photon counting CTs really redefine what a CT can do, and will allow us to image with those lower radiation doses as well as some increased what we call contrast resolution or spatial resolution, which means how sharp those images are.

So, when people are talking about getting new scanners at different institutions, I really feel like the photon counting CTs are going to be sought after more than the other conventional CTs, because of some of these benefits that they allow to what we would've seen in traditional, more conventional imaging, with all of these benefits of reduced dose, faster scanning and better spatial resolution in the images.

Sanket Shah, MD, MHS, FAAP: Yeah. Dr. Gubara, if I could add to your point. I think so because of the lower radiation in, the new photon counting CT, we have used it in valve planning surgeries. Uh, instead of MRI. Our MRI magnet is very busy and, we not only get precise anatomical information but also we have used now this with lower radiation for functional information that MRI used to provide us. So, it is supplementing, and complimenting our other imaging techniques, in a good way.

Host: That sounds wonderful. So that leads me to the question about working with multidisciplinary teams. How easy has it been to integrate this new technology? Has it been more collaborative, or have you encountered challenges?

Erin Opfer, DO: Since we've gotten our new photon counting CT scanner and we just got it in May. It really has been a great collaborative effort especially with the cardiology department, developing how we can best use that scanner, which ways that we're going to protocol and scan patients with it.

And we have started a collaborative approach where we both will help determine what is the best way to image each individual patient is, we'll have a discussion between the two teams. Once we get the imaging, we both review the imaging. So, it has both a cardiologist and a radiologist reviewing the images and putting in a combined collaborative report, which I think is the best of both worlds and really is beneficial for the patients to have both inputs, for their imaging and their reporting.

Sanket Shah, MD, MHS, FAAP: I couldn't agree more. I think, this has fostered more collaboration and our patients at the end of the day, are the most beneficiaries of having inputs and expertise from two different specialties, kind of working in as a team for their best outcomes and best clinical care.

Host: That's so wonderful to hear about the collaboration between your specialties. Dr. Shah, can you tell us more about the clinical impact you've seen on families, specifically with kids in cardiology?

Sanket Shah, MD, MHS, FAAP: So, a couple of cases from my own individual patients in the last couple months come to mind. We had a child on our cardiology floor who on echo imaging, we suspected that there is limited blood flow or no significant blood flow to the left lung. And it was Friday at 4:00 PM and I called Dr. Opfer's team and, and they were able to get a CT scan done, right away. And that confirmed that there was no blood flow going to the left lung. And the child actually went to the operating room Friday night, recovered in the ICU over the weekend and was back on the cardiology floor Monday after the blood flow was established. And that just is fantastic care, you know, the child was not or asymptomatic. And, without the CT scan, the child probably could have stayed a couple more days in the hospital till we would've been able to diagnose and offer surgery and that just optimized not only the patient's care, but hospital's resources. The child was able to go home sooner and that bed was freed up for another patient.

And, we were able to do what an ideal heart center and the hospital should do in our pediatric imaging and cardiac care. So that is one example. And the second example, I would say. I have a patient that's signed up actually for CT scan tomorrow, who is under five years of age.

And typically we would have to use anesthesia for that, for coronary imaging. And this one, with the, the speed and accuracy of the photon counting CT, we are going to be able to avoid the use of anesthesia, which is going to make this as a smooth patient experience and, less use of resources and time for the hospital to get the same amount as the same testing done.

Host: That's amazing. It sounds like you're able to deliver essential care with much better outcomes. Both of you mentioned the reduction in sedation. Dr. Opfer, how does faster scanning, and this technology reduce or eliminate that need for sedation?

Erin Opfer, DO: So a lot of times, with some of our older, conventional CTs, the exam can take longer time. It's, it's still a quick exam, but with the new photon and flash modes, it's much quicker. So we can do some of these scans, which we might have had to sedate the patient and, hold their breath artificially for them b y free breathing now with the new faster scanner, because instead of taking maybe two to five seconds for a CT scan, on our previous scanner, this scan may be less than a second, to obtain all the data. And so you can do that without needing to hold the patient's breath because that imaging acquisition is so quick.

So patients you might have typically had to sedate, you no longer have to sedate. Same thing with moving artifacts. Longer scans mean that if a patient moves, that you're going to see that in your images and cause some blurring. And so with a super quick, scan, you don't need to sedate them because the imaging happens, that quick.

And then when we're talking about cardiac patients, we're also having to take into account how fast their heart is beating. And so, these faster scan acquisitions, can also be done with children that have higher heart rates and younger children tend to have higher heart rates. So we can image even very small children without needing to sedate or use any methods to decrease their heart rate. And so we can get all that information, without the need to do those things in at even lower dose than what we used to before. So a lot of benefits to this new technology.

Host: That's incredible. Dr. Shah, do all of these benefits change how your department screens? Does it change diagnostic pathways or any guidelines for you?

Sanket Shah, MD, MHS, FAAP: Yes. One, I think it changes, since we can all get this quickly and easily, some of our out of town patients, for example, they don't have to make multiple trips. They can kind of get this test done the day before surgery and, we have the data right there to review, or the day of surgery.

And, there are certain conditions where, just to give an example of one is interrupted aortic arch where the ascending and descending aorta, have an interruption in the middle somewhere, is one condition where it wasn't considered appropriate use for imaging and our own internal data that we presented at conferences; we've shown that CT scan, this was us presenting at the World Congress of Pediatric Cardiology and Pediatric Cardiac Surgery in Hong Kong last month, that showed there was reduced mortality and reduced reoperation when CT scan was used for surgical planning for this particular condition.

So I think it is going to change guidelines in some of these complex anatomies of incorporating use of CT scan in that surgical decision-making.

Host: Amazing. So with changes in surgical decision-making, how much does image quality impact what, uh, physicians can distinguish now that they couldn't before using this technology? Dr. Opfer, can you weigh in on that?

Erin Opfer, DO: Well, some of the things that we might be able to distinguish better are patients that have implants or, any indwelling metal. We can see those better with the photon counting CT than we could with our conventional CTs. And the image quality, that we get really can impact how the surgeons can see the anatomy before they go in to do any surgical procedures on these patients. They have a good understanding of what the anatomy is, before they even attempt anything. And Dr. Shah may be able to expand a little bit more on that of how they use these images clinically.

Sanket Shah, MD, MHS, FAAP: One of the prime examples I find is in our neonate with coarctation of the aorta, where in addition to the coarctation, oftentimes the transverse aortic arch has hypoplasia, and that is a key determinant of the surgery needing Heart Lung Bypass machine, a cardiopulmonary bypass support or not.

And also the approach, whether the surgeons approach it from the front of the chest through a median sternotomy or through a posterolateral thoracotomy for just the coarctation repair. And I think on the new photon counting, alpha CT with the flash protocol, we've been able to get these images without breath holds on this neonates without anesthesia.

And that has led to, fantastic repair planning and with minimal residual aortic arch disease And I think that those patients and our surgeons, have a very low threshold now of obtaining this in case of the borderline size of the transverse arch So I think it has helped, in the smallest, the best.

Host: That's amazing. It sounds like it can help quite a lot of patients. Which leads me to my next question. Which patient population do you both think would benefit the most from photon counting CT today and why?

Erin Opfer, DO: So of the patients that we scan, specifically of the cardiac patients, like I previously mentioned, patients with implants or stents, the photon counting CT is helpful seeing through those, patient's with small structures like coronaries, we can see those due to the better spatial resolution and, image sharpness.

Also any radio sensitive patients, patients that might be getting multiple CTs over the course of their treatment, including the congenital heart disease patients or, oncology patients that might get multiple CTs over the course of their life because of the lower radiation with the photon counting CT.

Those are the patients that populations that I think are probably the best, with this newer technology.

Sanket Shah, MD, MHS, FAAP: I would add to that. I mean there is a wide variety of congenital heart disease spectrum that would benefit from this, but to just, to name a few is going to be several complex coronary artery disease, congenital coronary anomaly patients. Any, potential valve planning, operation or procedures in the cath lab, now it's part of the diagnostic armamentarium to obtain a CT scan. Anybody for re, redo sternotomy if this is a repeat surgery, a second or third open heart surgery. The surgeons benefit by knowing how much is the space between the sternum and the heart to do the operation safely?

The adult congenital heart disease population now, as, many of your listeners may know, there are more adults with congenital heart disease than pediatric patients with congenital heart disease. In those patients, traditionally have limited echo windows and, CT scan is, very, very important for defining their anatomy and in a lot of cases their physiology and function as well.

And I think, the aortic arch anomalies and coarctation type we talked about, but in general, there are only a few cases now that, the CT scans may not be helpful that much.

Sarah Gubara, PhD (Host): Dr. Shah, as you are training physicians and residents on using this technology, are there any technical considerations or steep learning curve that they should keep in mind for better outcomes?

Sanket Shah, MD, MHS, FAAP: Yeah, I think with any new modality, I think the, one of the things I emphasize, our trainees is to kind of learn the limitations and pitfalls. I mean, it is wonderful and has very limited pitfalls but at the same time, for any modality or diagnostic tool, you have to make sure that you know that, but also, know the, the mechanisms of how, how this technology work and works and how to optimize it because our patients have unique challenges like Dr. Opfer mentioned about moving heart, faster heart rates, and how to work with that physiology and, the features that the technology has. So those, are some things that I emphasize to our trainees.

Erin Opfer, DO: I would add to that, that a lot of the congenital heart patients, each of them are complex. And so, teaching the residents and fellows, this technology, you have to be able to think critically and, adapt how you're going to image each one individually to be able to best optimize visualizing the structures that would be clinically important.

 So walking them through how to think about those imaging and how to give contrast, is important.

Sanket Shah, MD, MHS, FAAP: I would totally agree with this. You know, not only where the IV needs to be and how much contrast and what kind of dilution of the contrast. And in some of these cases we have used them on while they are on heart lung bypass machine kind of ECMO machines and how to, you know, coordinate ECMO circulation while the CT scan is being performed. Those are highly deliberate tests. So they have to be thinking through every potential aspect of the physiology and the support that the patient is on.

Host: Amazing. Well, as we close out this interview, I have a last question for you about your vision for innovative healthcare at Children's Mercy. What are some promising changes or game changers that we can look for in this area?

Erin Opfer, DO: With this new CT scanner, I feel like we are going to be using it on more and more patients. We've already incorporated it into our daily CT, most of our patients are starting to get scanned on this CT scanner. And we are continuing to optimize the settings and things that we can do, the capabilities of this scanner.

And I feel like there are so many things that this scanner can do, that we are just at the tip of the iceberg right now, there's a lot of more things that we can employ this for. And so I look forward to seeing what we can do in the future with our imaging.

Sanket Shah, MD, MHS, FAAP: This is a Swiss army knife type tool that affects variety of imaging and rules in congenital heart disease care. And as I alluded to, it is on us to, make sure that we use it, in an appropriate manner to optimize surgical decision and, procedural decision and variety of situations like we talked about heart valve disease, adults with congenital heart disease. Coronary artery anomalies and a wide spectrum of congenital heart disease. But I think we have to find the most appropriate way to use this tool. It's going to their care for sure.

Host: Wonderful. Thank you to Dr. Sanket Shah and Erin Opfer. And thank you for listening to Transformational Pediatrics. To refer your patient or for more information, please visit children'smercy.org to get connected with one of our providers. This has been Transformational Pediatrics with Children's Mercy, Kansas City.

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