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

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.