Physiology-adapted cardiac CT angiography during veno-arterial ECMO in neonatal and pediatric postoperative congenital heart disease: feasibility and clinical impact

Q: What are the key findings of this study?

Physiology-adapted cardiac CT angiography during VA-ECMO identified pathology in 69% of examinations, provided info beyond echo in 85%, and directly guided intervention in 54% without adverse events.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Postoperative neonatal and pediatric congenital heart disease supported by veno-arterial ECMO (n=25). Intervention: Physiology-adapted cardiac CT angiography (CCTA) via arterial ECMO limb injection or intravenous injection with controlled ECMO flow modulation. Primary outcome: Diagnostic yield (identification of pathology, anatomical information beyond echocardiography, and direct impact on surgical or catheter-based intervention).

Q: What does this research mean for the field?

Physiology-adapted cardiac CT angiography during VA-ECMO is feasible and identifies clinically actionable anatomical findings beyond echocardiography that directly guide reinterventions in postoperative pediatric congenital heart disease. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Yishay Salem; Avshalom Shaffer; Jeffrey Jacobson; Orly Giotein; David Mishali; Evyatar Hubara; Tal Tirosh‐Wagner; Reut Kassif Lerner; Oliana Vazhgovsky; Mohamad Samara; Amir Vardi; Shai Tejman-Yarden

doi:10.1007/s00247-026-06822-9

November 11, 2026Pediatric RadiologyOpen Access

Physiology-adapted cardiac CT angiography during veno-arterial ECMO in neonatal and pediatric postoperative congenital heart disease: feasibility and clinical impact

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Key result

Physiology-adapted cardiac CTA identifies pathology in ~69% of patients on VA-ECMO.

n=25

Why the study?

In congenital heart disease patients on veno-arterial ECMO, altered systemic hemodynamics and contrast transit kinetics make conventional CT acquisition strategies unreliable. This study evaluated the feasibility, diagnostic yield, and clinical impact of a structured CCTA protocol adapted to ECMO-dependent physiology in postoperative neonatal and pediatric CHD patients.

Does a physiology-adapted cardiac CT angiography protocol improve diagnostic yield and inform therapeutic interventions in postoperative neonatal and pediatric congenital heart disease patients supported by veno-arterial ECMO?

Key Points

To evaluate the feasibility, diagnostic yield, and clinical impact of a structured cardiac computed tomographic angiography (CCTA) protocol tailored to ECMO-dependent physiology in postoperative neonatal and pediatric congenital heart disease patients.
Retrospective, single-center cohort study (2013–2022) evaluating consecutive postoperative neonatal and pediatric congenital heart disease patients (N=25; 26 examinations; median age 133 days; median weight 5.1 kg) undergoing clinically indicated CCTA during veno-arterial ECMO.
Imaging was performed on a 256-slice CT scanner using ECG gating, with contrast delivered either via the arterial ECMO limb (n=15) or intravenously with transient ECMO flow reduction (n=11) based on clinical indication and circuit flow.
CCTA revealed pathological findings in 18 of 26 examinations (69%) and provided anatomical detail beyond echocardiography in 22 of 26 cases (85%).
Zero transport-related or CT-related adverse events occurred during the examinations.

Study Design

Type

Cohort (n=25)

Multicenter

No

Structured PICO

Does a physiology-adapted cardiac CT angiography protocol improve diagnostic yield and inform therapeutic interventions in postoperative neonatal and pediatric congenital heart disease patients supported by veno-arterial ECMO?

P

Population

25 postoperative neonatal and pediatric congenital heart disease patients (median age 133 days, 32% female) supported by veno-arterial ECMO undergoing 26 clinically indicated cardiac CT angiography examinations.

E

Exposure

Structured physiology-adapted cardiac CT angiography (CCTA) protocol on a 256-slice ECG-gated scanner with contrast route and scan timing individualized to ECMO circuit flow: either direct arterial ECMO limb injection at 4-5 mL/s (15 examinations) or intravenous injection at 2-3 mL/s with transient (<90 seconds) ECMO flow modulation/reduction and optional temporary saline bridge opening (11 examinations).

O

Outcome

Feasibility, diagnostic yield (identification of pathology and anatomical information beyond transthoracic/transesophageal echocardiography), and clinical impact (directly informing surgical or catheter-based intervention).surrogate

Adapting cardiac CT angiography contrast administration and timing to ECMO circuit physiology safely yields high diagnostic accuracy and directly guides surgical or catheter re-intervention in over half of critically ill postoperative pediatric CHD patients when echocardiography is inconclusive.

Limitations

Small sample size (25 patients, 26 examinations), precluding formal statistical comparison between acquisition strategies or subgroup analyses
Retrospective, single-center design introducing selection bias and limiting generalizability
Image quality was not evaluated using a standardized quantitative scoring system
Observational design did not allow outcomes such as ECMO weaning or survival to be attributed specifically to CCTA findings
Multidisciplinary expertise and institutional infrastructure needed to implement this protocol safely may not be universally available
Small sample size (25 patients, 26 examinations) precluding formal statistical comparison or subgroup analyses
Observational design did not allow outcomes such as ECMO weaning or survival to be attributed specifically to the CCTA findings
Requirement for specialized multidisciplinary expertise and institutional infrastructure that may not be universally available

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Answers are grounded in this paper and cite their sources.

Implication

May inform interventions when echocardiography is inconclusive in VA-ECMO-supported pediatric CHD; leaves open prospective validation in larger cohorts.

Abstract

Background Cardiac computed tomographic angiography (CCTA) provides high-resolution anatomical assessment in cases of congenital heart disease (CHD). This is crucial in patients supported by veno-arterial extracorporeal membrane oxygenation (VA-ECMO), since the fundamental alteration of systemic hemodynamics and contrast transit kinetics makes conventional CT acquisition strategies unreliable. We evaluated the feasibility, diagnostic yield, and clinical impact of a structured CCTA protocol adapted to ECMO-dependent physiology in postoperative neonatal and pediatric CHD patients. Methods This retrospective, single-center cohort study (2013–2022) included all consecutive postoperative neonatal and pediatric patients with CHD who underwent clinically indicated CCTA while supported by VA-ECMO subsequent to cardiac surgery. Contrast administration route and scan timing were individualized according to ECMO circuit flow characteristics and clinical indication. Results Twenty-six CCTA examinations were performed in 25 patients ranging in age from 3 days to 14.8 years (median age 133 days; median weight 5.1 kg). Contrast was administered via the arterial ECMO limb in 15 cases and intravenously with controlled ECMO flow modulation in 11. In 18 of the 26 examinations (69%) the examination revealed a pathology. CCTA provided anatomical information beyond echocardiography in 22 of 26 cases (85%) and directly informed a surgical or catheter-based intervention in 14 cases (54%), with procedural confirmation in all. No transport-related or CT-related adverse events occurred. Conclusion When acquisition protocols are adapted to ECMO-dependent hemodynamics, CCTA is feasible and diagnostically consequential in neonatal and pediatric patients supported by VA-ECMO after congenital cardiac surgery. A physiology-guided strategy enables consistent vascular enhancement and frequently identifies clinically actionable findings not detected by echocardiography which can directly inform therapeutic decision-making in this critically ill population.

Discussion

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Cite This Study

Salem et al. (2026) conducted a cohort in Postoperative neonatal and pediatric congenital heart disease supported by veno-arterial ECMO (n=25). Physiology-adapted cardiac CT angiography (CCTA) via arterial ECMO limb injection or intravenous injection with controlled ECMO flow modulation was evaluated on Diagnostic yield (identification of pathology, anatomical information beyond echocardiography, and direct impact on surgical or catheter-based intervention). Physiology-adapted cardiac CT angiography during VA-ECMO identified pathology in 69% of examinations, provided info beyond echo in 85%, and directly guided intervention in 54% without adverse events.

synapsesocial.com/papers/6af6545d78c9af7e1faf1787 https://doi.org/10.1007/s00247-026-06822-9

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Physiology-adapted cardiac CT angiography during veno-arterial ECMO in neonatal and pediatric postoperative congenital heart disease: feasibility and clinical impact

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Physiology-adapted cardiac CT angiography during veno-arterial ECMO in neonatal and pediatric postoperative congenital heart disease: feasibility and clinical impact

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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