InterviewonCardiacImagingNorway/Dr.YlvaHaig&Dr.EinarHoppWorkingasaradiologistisagreatchallengeasthetechnicaldevelopmentsareimmense,andradiologicalexaminationshavebecomemuchmoreimportantfordetaileddiagnoses,preoperativeassessmentandfollow‐up,Dr.YlvaHaigandDr.EinarHoppfromOslostate BothDr.YlvaHaigandDr.EinarHoppareseniorconsultantradiologistsatOsloUniversityHospital.Dr.HaigworksatUllevålandAkerHospitalswhichhascombinedlocalandsecondaryreferralfunctionswithsometertiaryandnationalreferralfunctions.Dr.HoppworksatRikshospitaletwhichisasmallerpartofthehospitalwithtertiaryandsomenationalreferralfunctions.ThiscombinedsimilarityanddiversityisthereasonwhyDrs.HaigandHoppchosetoanswersomequestionsseparatelyandsomeasone.EuropeanSocietyofRadiology:Couldyoupleasegiveadetailedoverviewofwhenandforwhichdiseasesyouusecardiacimaging?YlvaHaig:Weperformcardiacimaginginbothhospitalisedpatientsmainlyreferredfromourcardiacandthoracicdepartments,andpatientsreferredfromotherhospitalsinourhealthregionandexternalcardiologists.Themajorityofourpatientshaveclinicalsymptomsorsuspicioussignsofischaemicdisease,acutemyocardialorpericardialaffection,orcardiomyopathy.EinarHopp:Inaddition,atthetertiaryreferralcentreatRikshospitaletsomepatientsareadmittedbecausetheyarecloselyrelatedtopeoplewithgeneticcardiacdisease,andthereisalargepatientgroupwithcongenitalheartdisease,bothnew‐borns,olderchildrenandgrown‐ups.ESR:Whichmodalitiesareusuallyusedforwhat?YH&EH:IntheDepartmentsofRadiologyatUllevålandRikshospitalet,weperformcardiacimagingwithCTandMRI.Thepatientsmay

undergoothertypesofcardiacimagingsuchasechocardiographyintheDepartmentofCardiologyorcardiacscintigraphyandaPETscanintheDepartmentofNuclearmedicine.Overthelastfewyears,CThasbecomeanestablishedmethodforthediagnosticinvestigationofcoronaryarterydiseaseinpatientsclassifiedatlowtointermediateriskofcoronarydisease,withtypicaloratypicalsymptomsofangina.CoronaryCThastoalargeextentreplacedinvasivediagnosticcoronaryangiography.Themodalityiscommonlyusedtodetectatherosclerosisandstenosesandhasahighnegativepredictivevalue.WealsoroutinelyperformcardiacCTpreoperativelyinpatientspriortoTAVI(transcatheteraorticvalveimplantation)andleftatrialappendageclosureprocedures.CardiacMRIiscommonlyusedinpatientswithischaemiatocharacterisetheextentandseverityofmyocardialinvolvementinadditiontopatientswitharrhythmiaspriortoICDimplantation.MRIisusedforthediagnosticworkupwhenarrhythmogenic

rightventricularcardiomyopathyissuspectedandisessentialintheassessmentofhypertrophiccardiomyopathyanddifferenttissuedepositiondiseasesfordiagnosticpurposesandriskstratification,butlesssoindilatedcardiomyopathy.Additionally,themodalityisoftencentralinvisualisingtheanatomicaldistributionandcharacterofcardiactumours.However,cardiacCTmayalsobevaluablehere,andthemodalitiesmaybecomplementary.Intheacutesetting,cardiacMRIisperformedonpatientswithsuspectedperi/myocarditis,andsubacutelytodetectandcharacterisecardiomyopathies.InthecaseofcongenitalheartdefectsbothCTandMRIareusedfordifferentpurposesatdifferentstages.WithMRIweassessintracardiacanomalies,myocardialtissueandflow.CTisstillimportantfortheassessmentofvascularvariants,eveninsomesmallchildren.ESR:Whatistheroleoftheradiologistwithinthe‘heartteam’?Howwouldyoudescribethecooperationbetweenradiologists,cardiologists,andotherphysicians?YH&EH:Wemeetregularlyanddiscusspatientsandoptimalimagingmethodsandparticipateineachother’smeetingsweekly.Thepatientsareusuallyreferredbythecardiologistsorthethoracicsurgeonsandtheradiologistplaysacentralpartinselectingtheoptimalimagingmodalityandprotocol.NowwealsohaveanincreasingcooperationregardingMRIexaminationsofpatientswithapacemakerorimplantablecardioverterdefibrillator.ESR:Radiographers/radiologicaltechnologistsarealsopartoftheteam.Whenandhowdoyouinteractwiththem?YH&EH:WehavededicatedandexperiencedradiographerswhoperformallthecardiacMRIimaging,whereasmostoftheradiographershavetrainingincoronaryCTimaging.Theyalwayscontactuswhenindoubt.YH:InmydailyworkintheangiosuiteIalsohavecloseteamworkwithourinterventionalradiographers.ESR:Pleasedescribeyourregularworkingenvironment(hospital,privatepractice).Doescardiacimagingtakeupall,most,or

onlypartofyourregularworkschedule?Howmanyradiologistsarededicatedtocardiacimaginginyourteam?YH:Cardiacimagingisoneofmanytasksandaccountsforlessthanhalfofmytimeatwork.WeareapproximatelytenradiologistsinvolvedintheevaluationofthecoronaryCTimagingandtwowhohandleallthecardiacMRI.EH:CardiacMRIconstitutesapproximatelyhalfofmyradiologicalpractice,buthasalargershareofmyresearchschedule.AtRikshospitaletwearebuildingateamoffourradiologistsperformingbothcardiacCTandMRIingrown‐ups,andwehaveasimilarnumberofpaediatricradiologistsperformingtheexaminationsincongenitalheartdefects.ESR:Doyouhavedirectcontactwithpatientsandifyes,whatisthenatureofthatcontact?YH&EH:Regardingthecardiacimagingpatientswealwayschooseappropriateprotocolsbeforetheexamination.AsforthecardiacCT,IattendtheCTlabonrequestfromtheradiographers,usuallyfortheadministrationofmedication,andsometimestoreviewtheexaminationbeforethepatientistakenfromthelab.IammorecloselyinvolvedincardiacMRIimaging.DependingonthepurposeoftheexaminationImaybepresentduringtheexaminationorjustbeconsultedalongtheway.ESR:Ifyouhadthemeans:whatwouldyouchangeineducation,traininganddailypracticeincardiacimaging?YH:AscoronaryCThasbecomearoutineexaminationandtoalargeextentreplacedinvasivecoronaryangiography,IbelieveitisimportantthattrainingincardiacandespeciallycoronaryCTisimplementedindoctors’radiologicalspecialtytrainingprogramme.EH:Istronglysupportthatpointofview.EveninroutinethoracicCTscans,somecardiacdiagnosesarereadilymade,callingfordeeperknowledgeamonggeneralradiologists.Probably,cardiacMRIwillstaysubspecialised,buttheneedforgeneralknowledgeinMRIforeveryradiologistisobvious.

ESR:Whatarethemostrecentadvancesincardiacimagingandwhatsignificancedotheyhaveforimprovinghealthcare?YH:Thetrendtowardsmorenon‐invasivediagnosticexaminationwithcoronaryCTisamajorchangewithfewercomplicationsandcostsinvolved.ThedevelopmentofcombinedCTandfractionalflowreserve(FFR)tomeasurethehaemodynamicsignificanceofastenosisisanotherinterestingandvaluabletechnique;however,thesoftwareisnotyetcommerciallyavailableintoday’sCTscanners.CardiacMRItechniquesarefurtherdevelopingandwilllikelyprovideuswithadditionalinformationandstratificationoncardiomyopathiesandtumoursinthefuture.EH:TechnologicalimprovementisobviousbothforCTandMRIexaminations.ForCT,broaderdetectors,higherspeedandthepossibilityforlowerandevennumerousvoltagesincreasequality.ForMRI,thenumerousdifferentimprovementsofdifferentsequences,higherspeedandanumberofrecentlyavailablemethodsbothincreasethenumberofrelevantparameters.Mostimportantly:forbothmethods,theadvanceshaveincreasedourabilitytoexamineabroaderrangeofthepopulation.Analysissoftwarehasbecomequicker,morestable,andmoreadvanced.Still,thereseemstobepotentialforfurtherimplementationandfurtherimprovement.Someadvancesinothermedicaldisciplinesinfluenceimaging:developmentingeneticshasprovidedmorepreciserecruitmentforcardiomyopathyassessment.Improvedcardiologicalknowledgeandwork‐uphasincreasedthedemandforbetterriskassessmentincardiacdisease.Demandforadvancedimagingseemstohaveincreased.Probablythisisacombinedeffectfromincreasedavailabilityandtheadvancesmentionedabove.ESR:Inwhatwayshasthespecialtychangedsinceyoustarted?Andwheredoyouseethemostimportantdevelopmentsinthenexttenyears?YH:Radiologyasaspecialtyhasandischangingatgreatspeed.Workingasaradiologistisagreatchallengeasthetechnicaldevelopmentisimmense,

continuouslyleadingtoimprovedimagingwithmoreandmoreinformation.Itischallengingtokeepuptodatewiththenewavailabletechniquesandallthepossibleadvantagestheybring.Simultaneously,asnewmedicaltreatmentsareintroduced,thedemandforradiologicalassessmentisincreasing.EH:Radiologicaldevelopmentisdrivenbothbymedicalandbytechnologicalprogress,andthemixispowerful.Ingeneral,theradiologicalrolehaschanged,andradiologicalexaminationshavebecomemuchmoreimportantfordetaileddiagnoses,preoperativeassessmentandfollow‐up.Eachexaminationcallsformoredetailedinvestigation,andevenreportinghasbecomemoredemanding.Theradiologistherselfisevermorecentralinmultidisciplinaryteams.Letusaddthefactthateveryradiologicalexamnowisseveraltimeslargerthanjustafewyearsago,andthatthedetailedimagingalsohasthepotentialforfindingrelevant,unknowndiseaseinneighbouringorgans.Thus,radiologyhasbecomeincreasinglyinteresting,andradiologicallabourincreasesveryfast.Staffdonotincreaseatthesamespeed.Thenexttenyearswewillhavetofollowanddrivetheupcomingprogress,butwealsohavetoreconsiderthewayweworkinordertocopewiththedemands.Redefiningworkflow,rolesandcomputeraid,anddevelopmentofautomatedproceduresareprobablypartsofthis.ESR:Isartificialintelligencealreadyhavinganimpactoncardiacimagingandhowdoyouseethatdevelopinginthefuture?YH:Wehavenotimplementedartificialintelligenceinourhospital,butIthinkithasanimmensepotentialinthefutureandwillinfluenceandchangeourworkroutines.However,withourexistingITsystemIdonotseethisinthenearfuture.EH:Artificialintelligence(AI)doesnotseemtodirectlyinfluencecardiacCTorMRIdiagnosticsatourhospital,presently.ThepotentialmaybelargeandaccordingtoQ9,theneedaswell,bothfromAIandmoretraditionallydevelopedsoftware.Thereisamagnitudeofpossibilities.Pre‐examtextscreeningmighthavethepotentialtodetectrisksbeforecontrast

mediumadministrationorexposuretothemagneticfield.Pre‐examimagescreeningmightinfluenceprotocolplanningoftheexamination.Fusionwithorsubtractionfromhistoricalexamsorothermodalitiesmighthighlightrelevantchangesbetterthanwearepresentlyableto.Bettersoftwaremayincreasesegmentationspeedandaccuracy,andevendecreasetheneedforexpertinvolvement.Reportingmightbemorestandardisedandcontentmayimprovewithnew,relevantparameters.Alltheseprocessesmaybecomemoreautomatedthantoday,decreasingthe

radiologist’sworkburden.Wewillhavetorethinklocalanddistantdevelopment,investmentandrisk.However,thecostisunknownandthebenefithastobedefined.Thetestisthesimplequestion:doesitimplyanybenefittothepatient’shealth,forsufficientlylowcost?AndwehavetogetintotheblackboxofAI,anddemandexplainableAI.Asalways,theradiologists,clinicaldoctors,technicalstaffandscientistshaveapivotalroleinthedevelopmentandtestingofallnewtechnology.Ibelieveworkingroleswillchange,buttaskswillcontinuetoincrease.

Dr.YlvaHaig isan interventionalradiologistat theDepartmentofRadiology atUllevål andAker in the unit of vascular, thoracic andintervention radiology, Oslo University Hospital, Norway. AftercompletingmedicalschoolattheKarolinskaHospital inStockholm,Sweden, Dr. Haig moved to Norway where she trained in generalradiologyandbecameaspecialistin2007.During her specialty training, she developed a special interest incardiac radiology and interventional work and was introduced topercutaneous coronary angiography and intervention procedures.She also participated in the first implementation of cardiac CT atOsloUniversityHospital,Ullevål,andisnowinchargeofdeveloping

and implantingnewcardiacCT techniquesat thehospital. InrecentyearsshehasalsobeenamajorcontributorinthecardiacMRIactivityatherhospital.Hermain research interesthas alsobeenwithin cardiac and interventional radiology and shecompleted her PhD thesis on Catheter‐directed thrombolysis in deep Venous Thrombosis (theCaVenT study) in 2015 and is now the research group leader of vascular diagnostics andinterventionatOsloUniversityHospital and currently supervisingaPhD thesison cardiacCTimaginginhigh‐riskpatientgroups.In 2016 Dr. Haigwas awarded at Oslo University Hospital for outstanding research and firstauthorshipofaresearchpaperselectedastop10%atCIRSE(CardiovascularandInterventionalRadiological Society of Europe) and nominated to the best‐paper session at the AmericanVenous Forum, 2017 in New Orleans. Since 2015 she is the treasurer in the Society ofInterventional Radiology in Norway (NFIR) and in 2017 obtained the Swedish InterventionalRadiologistcertification(SCIR).Sheisauthororco‐authorof11scientificpapers.Dr.EinarHoppisHeadoftheDepartmentofRadiology,Rikshospitalet,OsloUniversityHospital(OUH).HisPhDincardiacMRIwasdefendedin2014. After focusing on paediatric radiology, hismain diagnostic andresearch interests became non‐invasive cardiac radiology and ENTradiology.He has authored and co‐authored 30 scientific papers, two bookchapters and 48 scientific posters and presentations, and has givennumerous invited lectures, tutorials and refresher courses at nationalandinternationalmeetings.AtRikshospitalet,OUH,heisresponsibleforthoracicandENTMRI,andheisheadoftheresearchgroupofnon‐invasivecardiacimagingattheClinicofRadiologyandNuclearMedicine,OUH.He isaboardmemberandtreasureroftheNorwegianSocietyofRadiology.