harvard medical school coronary mdcta applications thomas h. hauser md, mmsc, mph, facc director of...
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Harvard Medical School
Coronary MDCTA Applications
Thomas H. Hauser
MD, MMSc, MPH, FACCDirector of Nuclear Cardiology
Beth Israel Deaconess Medical CenterAssistant Professor of Medicine
Harvard Medical SchoolBoston, MA
Harvard Medical School
Outline
• Possible indications for coronary MDCTA• How to approach a coronary MDCTA study
Harvard Medical School
Outline
• Possible indications for coronary MDCTA• How to approach a coronary MDCTA study
Harvard Medical School
Possible Indications for Cardiac CT
• Coronary artery – CAD/Plaque
– Stents
– Grafts
– Anomalous coronaries
• Ventricular size and function
• Valve imaging
• Myocardial perfusion
• Infarct imaging• Cardiac vein imaging
• Congenital heart disease
• Cardiac masses
• Cardiomyopathy
• Pulmonary vein imaging
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Detection of CAD
Accuracy investigators, RSNA 2007
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Clinical Evaluation of
Coronary CTA
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Multi-Center Trial: 16-Slice MDCT
Garcia, M. J. et al. JAMA 2006;296:403-411.
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Multi-Center Trials: CORE-64, Accuracy
• CORE-64 reported at AHA 2007 (Toshiba)– 291 patients at 9 institutions
– Sensitivity 85%
– Specificity 90%
– Excluded patients with calcium score >600
• ACCURACY reported at RSNA 2007 (GE)– 229 patients at 16 institutions
– Sensitivity 93%
– Specificity 82%
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ACCURACY Trial
J Am Coll Cardiol Budoff et al. online only
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Limitations of Coronary CTA
• Coronary Motion • Slab artifacts
– Ventricular Ectopy
– Ventilatory Motion
• Calcium• Stents• Radiation Dose
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Coronary Motion
Hoffmann et al, J Nucl Med 2006; 47:797–806
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Higher Heart Rate = More Motion
Hoffmann, M. H. K. et al. Radiology 2005;234:86-97
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Slab Artifact
Hoffmann et al, J Nucl Med 2006; 47:797–806
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Calcium
Hoffmann et al, J Nucl Med 2006; 47:797–806
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Calcium
Raff et al, J Am Coll Cardiol 2005;46:552–7
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Stents
Gaspar, T. et al. J Am Coll Cardiol 2005;46:1573-1579
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Stents
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Grafts
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Grafts
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Grafts
Harvard Medical School
Grafts
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Grafts
Vessels Segments Sens Spec
Grafts 109 182 99% 96%
Run-off 109 123 89% 93%
Non-BP 116 288 97% 86%
Malagutti et al. Eur Heart J 2006 epub
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Radiation Dose: High
Einstein et al, JAMA. 2007;298:317-323.
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Radiation Dose
J Am Coll Cardiol Maruyama et al. 52 (18): 1450
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Radiation Dose
J Am Coll Cardiol Maruyama et al. 52 (18): 1450
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Problems Correlating with Angiography
• Angiographic stenosis is not perfectly correlated with functional significance– Potential advantages for combining with functional
imaging
• Identification of non-obstructive plaque may identify patients at increased risk for adverse events– Ongoing prospective studies of prognosis
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Angiographic vs. Functional Stenosis
Meijboom et al, J Am Coll Cardiol, 2008; 52:636-643
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Outcomes after CTA
Ostrom et al, J Am Coll Cardiol, 2008; 52:1335-1343
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Plaque Characterization
Leber et al, J Am Coll Cardiol, 2005; 46:147-154
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Anomalous Coronary Arteries
http://bhavin.typepad.com/cardiac_images/
Harvard Medical School
Anomalous Coronary Arteries
http://bhavin.typepad.com/cardiac_images/
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Ventricular Function
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Ventricular Function
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Ventricular Function: Compared to CMR
Segung et al, Circulation 2006;114:654-661; 31 patients
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Ventricular Function: Compared to CMR
Segung et al, Circulation 2006;114:654-661; 31 patients, radial method
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Valvular Function
http://bhavin.typepad.com/cardiac_images/
Harvard Medical School
Valvular Function
http://bhavin.typepad.com/cardiac_images/
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Aortic Stenosis
Pouleur et al, Radiology 2007;244:745-754
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Aortic Stenosis
Pouleur et al, Radiology 2007;244:745-754
Harvard Medical School
Aortic Stenosis
Pouleur et al, Radiology 2007;244:745-754
Agreement between multidetector CT and TTE in the detection of normal (AVA 2 cm2), mildly stenotic (AVA 1.2 cm2 and < 2.0 cm2),
moderately stenotic (AVA 0.8 cm2 and < 1.2 cm2), or severely stenotic (AVA < 0.8 cm2) aortic valve opening was excellent ( = 0.88, P < .001)
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Valvular Function
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Valvular Dehiscence
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Valvular Dehiscence
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Perfusion and Late Enhancement
Nieman et al. Radiology.2008; 247: 49-56
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Perfusion and Late Enhancement
Nieman et al. Radiology.2008; 247: 49-56
Harvard Medical School
Perfusion and Late Enhancement
Nieman et al. Radiology.2008; 247: 49-56
Harvard Medical School
Cardiac CT
• Possible indications for coronary MDCTA• How to approach a coronary MDCTA study
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How to Review a Coronary CTA Study
• Review the axial images– Interrogate multiple reconstructions at different points in the
cardiac cycle to determine which has the least amount of artifact
• If any abnormalities, further investigate them with MIPs MPRs, and curved MPRs.
• Volume rendered images can be helpful to communicate your findings– Generally not diagnostic– Especially helpful in graft cases
• The entire dataset beyond the heart needs to be reviewed to ensure that there are no other significant findings.
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Axial Stack
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Axial Slice
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MIP
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Volume Rendered Image
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cMPR with SAX and VA
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cMPR with SAX and VA, Orthogonal
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Importance of Interactive Reconstructions
Ferencik et al, Radiology: Volume 243: Number 3—June 2007
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Outline
• Possible indications for coronary MDCTA– Coronary artery imaging is becoming established
• Stenosis
• Plaque characterization
• Stents
• Grafts
– Ventricular function
– Aortic Stenosis
• How to approach a coronary MDCTA study– Axial images contain all of the primary data
– Use interactive reconstructions to aid in assessing problem areas
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