1. Dr. Muhammad Ayub, FCPS
Diplomate Certification Board of Nuclear Cardiology
Diplomate Board of Cardiovascular Computed Tomography
Department of Cardiovascular Imaging
Punjab Institute of Cardiology Lahore

2. Cardiac CT
Technical considerations
 Spatial Resolution 0.4mm
 Temporal Resolution 85ms-200ms
 Contrast 70-100ml
 Radiation 6-13 msv

3. Cardiovascular CT
+
 Noninvasive
 Fast
 Calcium Scoring
 3D anatomic information
 Can see beyond lumen (atheroma imaging)

4. Cardiovascular CT
_
 Contrast
 Radiation
 Limited spatial resolution
 Limited Temporal Resolution(Requires slow heart rate)
 No hemodynamic information
 Technical Artifacts
 Limitation in patients with high coronary calcium

5. Types of studies
 Without contrast (Calcium Scoring)
 Contrast studies (CT Angiography)

6. Calcium Scoring

7. Coronary Calcium Scoring

8. CT Coronary Angiography

9. Appropriateness Criteria

10. Pre test Probability for CAD
Low Probability (<10%)
Asymptomatic men and women of all ages
Women < 50 years with atypical chest pain
Intermediate Probability (10%-90%)
Men of all ages with atypical angina
Women ≥ 50 years with atypical angina
Women 30-50 years with typical angina
High Probability
Men ≥ 40 years with typical angina
Women ≥ 50 years with typical angina

11. CT Angiography:
Appropriate Indications (Median Score 7–9)
 Detection of CAD:
Symptomatic—Evaluation of Chest Pain Syndrome Score
Intermediate pre-test probability of CAD.
ECG un-interpretable OR unable to exercise. A (8)
ECG interpretable and able to exercise. A (7)
Low pre-test probability of CAD.
ECG un-interpretable OR unable to exercise. A (7)

12. Normal CT Angiogram

13. 51 year old male with atypical chest pain

14. Appropriate?
• 40 year male
• Smoker, FH
• Atypical chest pain
Appropriateness Criteria
Intermediate pre-test probability of CAD
ECG interpretable and able to exercise. A (7)

15. Appropriate?
 49 years old male
 No risk factors
 BMI of 26 m/Kg
 presented with new onset
angina FC II-III
Appropriateness Criteria
High pre-test probability of CAD
ECG interpretable and able to exercise. I (3)
ECG un-interpretable and able to exercise. U (4)

16. CCA confirmed the lesion PCI
of LAD with Cypher
kissing Balloon angioplasty of
Diagonal was done

17. Appropriate indications
35 year old male non smoker Hypertensive with occasional H/O post prandial chest pain
has had his ETT which was equivocal. CT Angio showed Normal Coronaries
Appropriateness Criteria
Diagnosis of Chest Pain
Equivocal stress test A(8)

18. Evaluation of suspected coronary anomalies
 50 years old male had CCA for
angina FC III but could not
engage RCA
 Referred for CT Angio for exact
localization and lesion of RCA
 CT Angio showed
 Anomalous origin of RCA from
LCC
Appropriateness Criteria
Detection of CAD:
Symptomatic—Evaluation of Intra-Cardiac Structures
Evaluation of suspected coronary anomalies A (9)

19. Evaluation of suspected coronary anomalies
 21 years old female
 SOB FC II
 Continuous murmur at base
 Normal Dimensions of LV and RV
 Continuous flow at LCC on CWD
Appropriateness Criteria
Detection of CAD:
Symptomatic—Evaluation of Intra-Cardiac Structures
Evaluation of suspected coronary anomalies A (9)

20. 48 year male with typical chest pain:
Suspected coronary anomaly on conventional angiogram
Appropriateness Criteria
Detection of CAD:
Symptomatic—Evaluation of Intra-Cardiac Structures
Evaluation of suspected coronary anomalies A (9)

21. Young girl following VSD repair:
Suspected Coronary Fistula into RVOT
Appropriateness Criteria
Detection of CAD:
Symptomatic—Evaluation of Intra-Cardiac Structures
Evaluation of suspected coronary anomalies A (9)

22. 35 year old male smoker Hypertensive with acute chest pain
CT Angio showed Normal Coronaries
Appropriateness Criteria
Detection of CAD: Symptomatic—Acute Chest PainIntermediate pre-test probability of CAD. No
ECG changes and serial enzymes negative A (7)

23. Assessment of Cardiac Masses
 48 year old male
 Known Case of AS
 Suspected Atrial mass, not
clearly visualized on echo
Appropriateness Criteria
Structure and Function—Evaluation of Intra- and Extra-Cardiac StructuresEvaluation of
cardiac mass (suspected tumor or thrombus). Patients with technically limited images
from echocardiogram, MRI, or TEE A (8)

24. AS, Myxoma

25. Assessment of Pericardial Conditions
Appropriateness Criteria
Evaluation of pericardial conditions (pericardial mass, constrictive pericarditis, or complications of cardiac surgery).
Patients with technically limited images from echocardiogram, MRI, or TEE A (8)

26. Assessment of Pulmonary Venous Anatomy
Appropriateness criteria
Evaluation of pulmonary vein anatomy prior to invasive radiofrequency ablation for atrial fibrillation A (8)

27. Assessment of Pulmonary Veins prior to
biventricular pacemaker
Appropriateness Criteria
Noninvasive coronary vein mapping prior to placement of biventricular pacemaker A (8)

28. Post CABG Assessment
Appropriateness Criteria
Assessment of graft patency in symptomatic patients A (8)
Noninvasive coronary arterial mapping, including internal mammary artery prior to repeat cardiac surgical revascularization A (8)

29. Assessment of Aorta
Appropriateness Criteria
Structure and Function—Evaluation of Aortic and Pulmonary Disease
Evaluation of suspected aortic dissection or thoracic aortic aneurysm A (9)

30. Aortic Dissection
Appropriateness Criteria
Structure and Function—Evaluation of Aortic and Pulmonary Disease
Evaluation of suspected aortic dissection or thoracic aortic aneurysm A (9)

31. Aortic Dissection

32. Aortic Study
Total Occlusion
Appropriateness Criteria
Structure and Function—Evaluation of Aortic and Pulmonary Disease
Evaluation of suspected aortic dissection or thoracic aortic aneurysm A (9)

33. Congenital Heart Disease
Aortic Coarctation

34. Interrupted Arch

35. Suspected Aortitis

36. Assessment of Pulmonary vessels
Appropriateness Criteria
Structure and Function—Evaluation of Aortic and Pulmonary Disease
Evaluation of suspected pulm embolism A (9)

37. Assessment of Congenital Heart Disease
Appropriateness Criteria
Assessment of Complex Congenital Heart Disease including anomalies of coronaries, great vessels, cardiac
chambers and Valves A(7)

38. Assessment of Complex Congenital Heart Disease
ASD
VSD
Appropriateness Criteria
Assessment of Complex Congenital Heart Disease including anomalies of coronaries, great vessels,
cardiac chambers and Valves A(7)

39. Assessment of Complex Congenital Heart Disease
SV ASD + PAPVD
Appropriateness Criteria
Assessment of Complex Congenital Heart Disease including anomalies of coronaries, great vessels, cardiac
chambers and Valves A(7)

40. Interrupted Arch

41. Congenital Heart Disease

42. Assessment of cardiac function
Appropriateness Criteria
 Evaluation of left ventricular function
 ● Following acute MI or in HF patients
 ● Inadequate images from other noninvasive methods A (7)

43. Assessment of Cardiac Valves
Appropriateness Criteria
Characterization of native cardiac valves
● Suspected clinically significant valvular dysfunction
● Inadequate images from other noninvasive methods A (8)

44. Assessment of prosthetic Valves
Appropriateness Criteria
Characterization of prosthetic cardiac valves
● Suspected clinically significant valvular dysfunction
● Inadequate images from other noninvasive methods A (8)

45. Uncertain Indications
Patent
Stent
Assessment of stents U(5)

46. CTA Limitations
 Rapid (>80 bpm) and irregular HR
 High calcium scores (>800-1000)
 Stents
 Contrast requirements (Cr > 2.0 mg/dl)
 Small vessels (<1.5 mm) and collaterals
 Obese and uncooperative patients
 RADIATION EXPOSURE

47. Thank you