With modern PCCT, pediatric cardiac CT can already achieve sub-mSv radiation doses; the commentary argues that further dose reduction should not automatically take priority when it compromises spatial resolution, image noise, edge sharpness, or diagnostic confidence.
Lower-kV PCCT protocols may reduce radiation dose, but there are important trade-offs: 70–90 kV Quantum mode can sacrifice ultra-high spatial resolution and material-specific spectral imaging, whereas 120–140 kV Quantum Plus mode enables low-keV VMI and spectral reconstructions such as virtual non-calcium and iodine-only imaging—potentially valuable for cardiovascular assessment.
The authors propose a shift from ALARA toward optimizing diagnostic performance and clinical impact: PCCT protocols should preserve sufficient image quality not only for human interpretation, but also for quantitative imaging, radiomics and AI, whose performance and reproducibility may deteriorate as radiation dose decreases and image noise increases.
