CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Ralph G. Brindis, MD, MPH, FACC*,
Christopher M. Kramer, MD, FACC,
Michael Poon, MD, FACC and
Geoffrey D. Rubin, MD, FSCBTMR
* Oakland Kaiser Medical Center, 280 West MacArthur Boulevard, Oakland, California 94611 (Email: ralph.brindis{at}kp.org).
We thank Drs. Cheong and Flamm for their concern about the use of nonelectrocardiographic (ECG)-gated computed tomographic angiography (CTA) in the evaluation of potential aortic dissection in the latest Appropriateness Criteria document (1). The American College of Cardiology Foundation Appropriateness Criteria Working Group has reviewed their letter, which was forwarded by the editor of JACC for our consideration.
Drs. Cheong and Flamm certainly raise an important point. To clarify, the listing of the indications and the technology used is not a "recommendation" for the use of non–ECG-gated CTA in the evaluation of potential aortic dissection. Instead, the expert panel rated the use of this technology as "appropriate" for the evaluation of aortic dissection. We certainly agree that, in many situations, the use of ECG gating would also be "appropriate" and likely would provide better image quality for assessing the relationship of an intimal flap with the structures of the aortic root, including the coronary arterial ostea. Depending on the method of ECG gating (retrospective vs. prospective), this may come at the cost of increased radiation exposure to the patient. The indications and specific imaging techniques as listed were not meant to be exhaustive, and the use of ECG gating was not purposefully excluded.
We will be certain that the issue Drs. Cheong and Flamm raised is brought to the attention of future Indication Writing Groups and Technical Panels responsible for updating this document. We also expect other documents and efforts within the American College of Cardiology will focus on the issue Drs. Cheong and Flamm raise in their letter and will be available for reference in future versions of the CT criteria.
We again thank him for bringing this issue to our attention and will use it along with the comments of others as we refine the Appropriateness Criteria process and documents going forward.
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References
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- Hendel RC, Patel MR, Kramer CM, et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology J Am Coll Cardiol 2006;48:1475-1497.[Free Full Text]
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