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Lecture vienna september 16 2005

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Lecture vienna september 16 2005

  1. 1. Noninvasive MDCT- based Imaging of the Coronary Arteries Udo Hoffmann, MD Director of Cardiac CT Research Assistant Professor of Radiology, Harvard Medical School Massachusetts General Hospital Boston, MA
  2. 2. Challenge of Coronary Artery Imaging Small Vessels with Complex Anatomy in Rapid Motion Cornerstone Invasive Selective Coronary Angiography
  3. 3. Prerequisites forPrerequisites for Successful Cardiac CTSuccessful Cardiac CT II • Temporal Resolution • Spatial Resolution • Volume Coverage
  4. 4. • 330- 400 ms gantry rotation (165- 200 ms) temporal resolution (half scan reconstruction) • 0.4 x 0.4 x 0.6 - 0.75 resolution • single breath hold 8 - 14 sec • 40 - 80 ml of contrast agent (4-5 ml/s) • 500 - 950 mAs tube current (modulation) • 7 – 24 mSv 64 Slice MDCT64 Slice MDCT Protocol for CoronaryProtocol for Coronary AngiographyAngiography
  5. 5. Prerequisites forPrerequisites for Successful Cardiac CTSuccessful Cardiac CT IIII • Appropriate Breath Hold exact instructions (mid inspiration) exercise and observe heart rate • Low heart rate, NSR (<65 bpm) Beta Blocker PO/IV
  6. 6. Retrospective ECG gating
  7. 7. Axial Source Images
  8. 8. Thin MIP 3D VRT Curved MPR Post Processing
  9. 9. P A C S Comprehensive Cardiac CT Examination betablocker i.v., sublingual Nitroglycerinebetablocker i.v., sublingual Nitroglycerine O F F L I N E
  10. 10. Detection of significant coronary artery stenosis
  11. 11. Systematic Review on Diagnostic Accuracy of CT- based Detection ofDetection of significant CADsignificant CAD • 30 studies • 1849 patients • 12913 coronary segments • 13 EBCT - 847 patients • 10 - 4/8 MDCT - 588 patients • 7 - 16 MDCT - 414 patients Hoffmann et al, JAMA 2005 submitted
  12. 12. Diagnostic Accuracy of EBCT, 4 - and 16 - slice MDCT Assessable Segments Pooled Sensitivity   97.5% CI     Pooled Specifici ty 97.5% CI All CT 83% 80.6%-85.3% 94% 93.2%- 94.6% EBCT 83% 79.5%-87.0% 90% 89.0%- 91.8% MSCT 83% 79.8%-85.7% 96% 95.1%- 96.5% 4- and 8-slice 82% 78.3%-85.2% 96% 95.0%- 96.6% 16-slice 86% 80.3%-91.4% 96% 94.4%- 97.1% All Segments       All CT 72% 69.5%-74.3% 84% 83.3%- 84.9%
  13. 13. RCA StenosisRCA Stenosis
  14. 14. n Sens. Spec. n.e. Ropers ACC 2005 84 91% 93% 7% Leschka Eur Heart J 2005 67 94% 97% -- Raff JACC 2005 70 86% 95% 12% Diagnostic Accuracy of 64- slice MDCT
  15. 15. Maximum Intensity Projection RCA 3D VRT LCX and RCA
  16. 16. Occlusion 1st diagonal branch
  17. 17. Multiplanar Reconstruction
  18. 18. Limitations TECHNICAL -- Calcium - Motion - Heart Rate CONCEPTUAL - Contrast, X-ray - Sinus rhythm - No intervention
  19. 19. - decrease number of purely diagnostic invasive selective coronary angiograms - complimentary to stress testing - improve early triage of patients with acute chest pain Potential Clinical Applications
  20. 20. Study Design early risk stratification in the ED decision to admit to hospital MDCT standard clinical care (blinded to MDCT) discharge diagnosis
  21. 21. Test Raw Data Overall Sensitivity 5/5 1 (0.49, 1) Specificity 26/35 0.74 (0.57,0.88) Accuracy 31/40 0.78 (0.62, 0.89) PPV 5/14 0.38 (0.13, 0.65) NPV 26/26 1 (0.87, 1) DOR 286 Overall Diagnostic Accuracy of MDCT (>50% stenosis) vs. ACS outcome
  22. 22. Patient without ACSPatient without ACS 43 year old female, 3 hours of substernal chest pain radiating to the back, negative initial Troponin and CK-MB, ECG: sinus bradycardia
  23. 23. • Patient with crushing chest pain • now relieved (Nitro) • Borderline ST- Elevation • No biomarker elevation Patient with ACSPatient with ACS
  24. 24. LAD Occlusion
  25. 25. LCX Anomaly and Stenosis
  26. 26. Perfusion Defect
  27. 27. Potential Impact on Decision Making Pretest Probability Posttest Probability P-value ACSACS 0.44±0.39 0.79±0.28 0.03 NoNo ACSACS 0.28±0.21 0.05±0.07 0.0001 Decrease average LOS in patients without ACS by 22 hours per patient
  28. 28. - decrease number of purely diagnostic invasive selective coronary angiograms - complimentary to stress testing - improve early triage of patients with acute chest pain - detect coronary anomalies Potential Clinical Applications
  29. 29. Anomalous Right Coronary Artery
  30. 30. - decrease number of purely diagnostic invasive selective coronary angiograms - complimentary to stress testing - improve early triage of patients with acute chest pain - detect coronary anomalies - determine bypass patency Potential Clinical Applications
  31. 31. • High sensitivity and specificity for arterial conduits and venous grafts • Limitations: distal Anastomosis in small vessels, metallic clips Martuscelli Circulation 2004 Bypass Graft Patency
  32. 32. - decrease number of purely diagnostic invasive selective coronary angiograms - complimentary to stress testing - improve early triage of patients with acute chest pain - detect coronary anomalies - determine bypass patency - improve risk predicition/ change definition of CAD Potential Clinical Applications
  33. 33. MPR of LAD in Cross SectionThin MIP Detection of Plaque Sensitivity 82%, Specificity 88% Achenbach et al. Circulation 2004
  34. 34. r = 0.64, p < 0.001 Moselewski et al. AJC 2004 Plaque Area Potential to detect and quantify coronary plaque
  35. 35. Plaque Composition Potential to discriminate calcified and non- calcified plaque Leber et al JACC
  36. 36. SummarySummary • Cardiac CT is a fast robust and highly reproducible noninvasive test • Lots of promise that it may change and improve management of patients with suspected or known CAD But no data available yet • Direct information on the presence and extent of CAD (stenosis and plaque), LV function and perfusion
  37. 37. MGH Cardiac CTA 2005MGH Cardiac CTA 2005 1. Core Lab for US Multi-center Trial on the Detection of Coronary Artery Stenosis with >1000 Patients 2. Cardiac CT for early triage in Patients with Acute Chest Pain 3. Core Lab for Siemens Multi-center Trial IVUS vs. MDCT 4. Non-Calcified Plaque (FHS) in Patients with Family History of premature CAD (Framingham) 5. Correction of Image Degradation in cardiac CT
  38. 38. Thank you Thank you

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