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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

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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

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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

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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/

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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/

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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

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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

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Perfusion and Late Enhancement

Nieman et al. Radiology.2008; 247: 49-56

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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