5 Pearls to Not Miss a Beat with Congenital Heart Disease Diagnosis

Across the United States, approximately 1.4 million adults are living with congenital heart disease, and for many, a trip to the emergency department is inevitable. Consequently, it is critical that emergency radiologists know the signs of – and potential problems associated with – this condition on imaging scans.

That’s the message that M. Zak Rajput, M.D., an emergency and abdominal radiologist with Washington University Physicians, shared during his presentation Oct. 2 at the American Society of Emergency Radiology (ASER) 2020 annual meeting.

“Imaging can play a critical role as many patients who had operations as infants and children have grown up and they are now living with congenital heart disease in their 30s, 40s, 50s, and beyond,” he told Diagnostic Imaging. “It’s important for radiologists to be aware of what to look for in adult patients presenting to the emergency department with a history of congenital heart disease.”

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Identifying congenital heart disease in patients can be complicated, he said, so he shared five pearls of wisdom that can best set emergency radiologists up for success.

1. Undiagnosed: It is possible, Rajput said, that the patient could have undiagnosed congenital heart disease.

“We may be the first providers to suggest this condition in patients coming through the emergency department,” he explained. “That’s certainly something to be aware of as congenital heart disease is associated with life-threatening conditions.”

For example, imaging might reveal a previously undetected bicuspid aortic valve or an atrioventricular canal defect that can put a patient at increased risk for a pulmonary embolism.

2. Clinically significant, but not life-threatening: Not every finding associated with this condition puts the patient’s life at risk. But, things could be clinically significant and could offer information about why he or she arrived at the emergency department to begin with.

For example, CT images could show a patient has a single left ventricle that could increase the likelihood that they will develop arteriovenous malformations or abnormal connections between their arteries and veins in their lungs, detrimentally affecting their ability to oxygenate their blood or leading to emboli. Their congenital heart disease could also prompt the formation of collateral arteries that can rupture, causing the patient to vomit blood and threatening lethality.

3. Mimics: Sometimes findings that look like congenital heart failure just are not so, Rajput said. In many of these cases, what the provider sees is the result of a surgical fix earlier in life.

“As emergency radiologists, we might not be aware of the appearance of some of these surgical techniques on imaging in adulthood, and they can often be confused with acute pathology that’s more serious,” he said.

For example, he added, it is possible for a surgical repair of an aorta to closely resemble an enlargement of the ascending aorta.

4. Non-contrast CT scan: Capture a non-contrast scan prior to one with contrast because surgical materials show up better without contrast, he said.

“Surgical material is usually very static, and we can see it better, oftentimes, on the non-contrast scan,” he said. “It helps us get the lay of the land initially.”

5. Delayed Phase: Emergency radiologists should consider acquiring a delayed phase to their routine CT protocol. Five seconds after capturing an image with contrast, secure a second image.

This is helpful, he said, because oxygenated and de-oxygenated blood, as well as blood that has been opacified with the contrast agent, frequently mix in patients who have had surgical repairs that have led to reconstructed anatomy. Taking an additional image shortly after the first can help radiologists determine whether they are detecting a real pathology or a normal artifact.

Ultimately, he said, it is important for radiologists to be aware of how congenial heart disease presents because the patient population is growing.

“Radiologists are going to be encountering these patients more and more in imaging as they get CT scans,” he said. “So, it’s really important for us to recognize and understand the emergent and critical findings that we see in these patients, as well as the techniques we can use to make these diagnoses to direct patient care.”