Incremental Value of Cardiovascular CT in Neonates and Infants with Congenital Heart Disease: An Integrated Multimodality Imaging Approach

Background: Transthoracic echocardiography (TTE) is the first-line imaging modality in neonates and infants with congenital heart disease (CHD), whereas cardiovascular computed tomography (CCT) is generally reserved for selected questions that remain unresolved after echocardiography. We evaluated the incremental diagnostic contribution of CCT within this multimodality imaging pathway. Methods: We retrospectively reviewed consecutive patients aged <1 year with CHD who underwent CCT after multidisciplinary review because TTE was inconclusive or additional anatomic definition was required for surgical planning. The primary endpoint was the incremental anatomic information provided by CCT beyond TTE. Secondary analyses included diagnostic performance against operative findings, acquisition characteristics, radiation exposure, contrast administration, and procedural safety. Results: Twenty-six patients were included; 14 (53.8%) were neonates. CCT was requested most frequently to assess coronary anatomy (9/26, 38.5%), followed by the pulmonary veins (4/26, 15.4%), aortic arch (3/26, 11.5%), and pulmonary arteries/MAPCAs (4/26, 15.4%). CCT provided additional anatomic characterization in 14/26 patients (53.8%), predominantly involving extracardiac vascular structures, and was discordant with TTE regarding the unresolved target anatomy in 12/26 (46.2%). Against the operative findings, TTE accuracy was 96.2% for intracardiac abnormalities, 41.2% for extracardiac abnormalities, and 11.1% for coronary abnormalities; corresponding CCT accuracy was 100%, 94.1%, and 100%. CCT directly informed the surgical approach in two patients with total anomalous pulmonary venous drainage. All examinations provided sufficient image quality to address the specific clinical question for which CCT was performed, and no contrast-related adverse events occurred. The median estimated effective dose was 3.62 mSv (IQR, 1.94–6.06). Conclusions: In a highly selected cohort of neonates and infants with CHD in whom expert TTE leaves a clinically relevant question unresolved, CCT may provide incremental information, particularly regarding coronary and extracardiac vascular anatomy. These findings support a targeted multimodality strategy in which CCT complements echocardiography and is tailored to the anatomic question relevant to surgical planning.