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Coronary MDCTA Applications

Coronary MDCTA Applications. Thomas H. Hauser MD, MMSc, MPH, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Assistant Professor of Medicine Harvard Medical School Boston, MA. Outline. Possible indications for coronary MDCTA How to approach a coronary MDCTA study.

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Coronary MDCTA Applications

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  1. Coronary MDCTA Applications Thomas H. Hauser MD, MMSc, MPH, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Assistant Professor of Medicine Harvard Medical School Boston, MA

  2. Outline • Possible indications for coronary MDCTA • How to approach a coronary MDCTA study

  3. Outline • Possible indications for coronary MDCTA • How to approach a coronary MDCTA study

  4. 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 Possible Indications for Cardiac CT

  5. Detection of CAD Accuracy investigators, RSNA 2007

  6. Clinical Evaluation of Coronary CTA

  7. Multi-Center Trial: 16-Slice MDCT Garcia, M. J. et al. JAMA 2006;296:403-411.

  8. 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%

  9. ACCURACY Trial J Am Coll Cardiol Budoff et al. online only

  10. Limitations of Coronary CTA • Coronary Motion • Slab artifacts • Ventricular Ectopy • Ventilatory Motion • Calcium • Stents • Radiation Dose

  11. Coronary Motion Hoffmann et al, J Nucl Med 2006; 47:797–806

  12. Higher Heart Rate = More Motion Hoffmann, M. H. K. et al. Radiology 2005;234:86-97

  13. Slab Artifact Hoffmann et al, J Nucl Med 2006; 47:797–806

  14. Calcium Hoffmann et al, J Nucl Med 2006; 47:797–806

  15. Calcium Raff et al, J Am Coll Cardiol 2005;46:552–7

  16. Stents Gaspar, T. et al. J Am Coll Cardiol 2005;46:1573-1579

  17. Stents

  18. Grafts

  19. Grafts

  20. Grafts

  21. Grafts

  22. 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

  23. Radiation Dose: High Einstein et al, JAMA. 2007;298:317-323.

  24. Radiation Dose J Am Coll Cardiol Maruyama et al. 52 (18): 1450

  25. Radiation Dose J Am Coll Cardiol Maruyama et al. 52 (18): 1450

  26. 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

  27. Angiographic vs. Functional Stenosis Meijboom et al, J Am Coll Cardiol, 2008; 52:636-643

  28. Outcomes after CTA Ostrom et al, J Am Coll Cardiol, 2008; 52:1335-1343

  29. Plaque Characterization Leber et al, J Am Coll Cardiol, 2005; 46:147-154

  30. Anomalous Coronary Arteries http://bhavin.typepad.com/cardiac_images/

  31. Anomalous Coronary Arteries http://bhavin.typepad.com/cardiac_images/

  32. Ventricular Function

  33. Ventricular Function

  34. Ventricular Function: Compared to CMR Segung et al, Circulation 2006;114:654-661; 31 patients

  35. Ventricular Function: Compared to CMR Segung et al, Circulation 2006;114:654-661; 31 patients, radial method

  36. Valvular Function http://bhavin.typepad.com/cardiac_images/

  37. Valvular Function http://bhavin.typepad.com/cardiac_images/

  38. Aortic Stenosis Pouleur et al, Radiology 2007;244:745-754

  39. Aortic Stenosis Pouleur et al, Radiology 2007;244:745-754

  40. Aortic Stenosis 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) Pouleur et al, Radiology 2007;244:745-754

  41. Valvular Function

  42. Valvular Dehiscence

  43. Valvular Dehiscence

  44. Perfusion and Late Enhancement Nieman et al. Radiology.2008; 247: 49-56

  45. Perfusion and Late Enhancement Nieman et al. Radiology.2008; 247: 49-56

  46. Perfusion and Late Enhancement Nieman et al. Radiology.2008; 247: 49-56

  47. Cardiac CT • Possible indications for coronary MDCTA • How to approach a coronary MDCTA study

  48. 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.

  49. Axial Stack

  50. Axial Slice

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