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
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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
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
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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