The divisions of Chest and Cardiac Imaging have been recently reorganized as Cardiothoracic Imaging. The division director, Dr. Czum, is fellowship-trained in cardiovascular MR and subspecialty board-certified in Cardiovascular CT. Dr. Black, an outcomes scientist and authority on lung cancer screening, divides his time between clinical and research endeavors, and is on the faculty of The Dartmouth Institute for Health Policy and Clinical Research. Dr. Savellano is a recent graduate of our residency program, with a significant research background in MR imaging.
Chest radiography and chest CT comprise a significant portion of the imaging performed in the department. Chest CT includes dedicated non-contrast imaging for interstitial lung disease, breathing maneuvers to assess obstructive airways disease, low radiation dose technique for follow-up evaluation of nodular disease, and contrast-enhanced CT pulmonary angiography, as well as standard protocols for airspace disease and oncology staging.
Non-invasive cardiovascular modalities include cardiac CT, coronary CTA, cardiac MR, and MR angiography. Cardiac MR structural and functional evaluation is used to evaluate pericardial, valvular, ischemic and non-ischemic heart disease, as well as cardiac mass evaluation. Pharmacologic stress MR perfusion imaging is an alternative to stress echocardiography and myocardial perfusion scintigraphy. The delayed enhancement technique is used to localize and quantify infarcted and viable myocardium, as well as to evaluate cardiomyopathies. ECG-gated 64-detector row CT is a robust means to non-invasively image the heart and coronary arteries in appropriate clinical circumstances.
With the aim of selecting the most appropriate evidence-based modality-protocol combinations for each patient’s unique circumstances, division staff consults on a daily basis with primary care providers and a range of specialists including pulmonologists, thoracic surgeons, thoracic oncologists, cardiologists, electrophysiologists, and cardiac surgeons. Daily intensive-care unit team rounds, weekly multidisciplinary thoracic oncology conferences, and monthly pulmonary-radiology conferences are characteristic of the collaborative approach to cardiothoracic care at DHMC.
A variety of new technologies continue to enhance the effectiveness of cardiothoracic imaging. Thin-client software available at all workstations permits real-time assessment of pulmonary nodule volume doubling time—an increasingly important means for discriminating benign from malignant lesions. Post-processing of airways image data creates virtual bronchoscopic reconstructions that aid in planning of transluminal interventions and surgery. Co-registration of 3D cardiac-MR or CT data with electrical maps permits radiofrequency ablation of lesions with increased safety, improved accuracy, and reduced complications. With increased surgical success in treating pediatric victims of congenital heart disease, cross-sectional MR or CT surveillance has become both more effective and more essential in monitoring chronic post-operative sequelae and in the timing of further interventions.
Radiology residents spend 14 weeks in cardiothoracic imaging rotation, as 4- or 5-week blocks in the first, third and fourth years. Didactic lectures (one pulmonary lecture and one cardiac lecture each month) are based on the knowledge- based objectives of the Society of Thoracic Radiology curriculum. The third and fourth year rotations include a cardiology option offering exposure to transthoracic and trans-esophageal echocardiography, invasive coronary angiography, and electrophysiology procedures. Cardiology fellows rotate through the department for experience in cardiac MR and CT, in addition to nuclear cardiology training. Pulmonary fellows and internal medicine residents spend the majority of their radiology elective time in chest imaging.
Medical student education includes lectures in chest imaging during second-year courses in pulmonary medicine and cardiology by Drs. Czum and Black, both of whom have received teaching awards. The regular fourth-year radiology elective includes participation in chest imaging read-out sessions; and, through the individually-tailored electives also available to third and fourth year students, the possibility of additional cardiothoracic imaging experience.
Dr. Black is one of the principal designers of the National Lung Screening Trial (NLST), a major multi-center trial comparing non-contrast CT with chest radiography in cancer screening of smokers; he is PI for Dartmouth- Hitchcock and also directs the study’s cost-effectiveness component.
Quality improvement projects being undertaken include systematic radiation reduction for chest CT studies as well as an ongoing collaboration with radiologic technologists using a PACS-based reporting system for image quality assurance that has resulted in improved problem-solving, performance metrics, and in-service education initiatives.
- Cardiac function and morphology (MR and CT)
- Cardiac MR/ MRA flow analysis
- Cardiac MR pharmacologic stress
- Cardiac MR rest perfusion
- Cardiac MR viability/scar imaging
- Chest radiology
- Congenital heart disease evaluation
- Coronary calcium scoring
- Coronary CTA
- CT angiography for evaluation of suspected pulmonary embolism
- CTA of coronary bypass grafts
- Expiration and prone (HRCT) of the chest
- High Resolution CT (HRCT) of the chest
- Left atrium/ pulmonary mapping (MR and CT)
- Low-dose CT for follow-up of small pulmonary nodules
- MRA/ CTA of aorta, pulmonary vein arteries, peripheral vasculature
- Peripheral bypass graft CTA
- Pre- and post-endograft CTA of aorta
- Standard (spiral) Computer Tomography (CT)
- Semi-automatic volumetric assessment of pulmonary nodules
- 3D/ 4D Image reconstructions
- Percutaneous needle biopsy
- Weekly interdepartmental thoracic oncology conference, as part of the Comprehensive Thoracic Oncology Program, for presentation and discussion of patients with known or suspected thoracic malignancies.
- National Lung Screening Trial, an ongoing multi-center randomized clinical trial of lung cancer screening funded by the National Cancer Institute
- Cardiac CT/ Coronary CTA angiography
- Cardiac MR
- CTA/ MRA of chest, abdomen, pelvis, and extremities (excluding neuro-vascular)
- Dartmouth Advanced Imaging Center: multi-disciplinary advanced cardiac imaging research
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