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Coronary CTA

Indications and interesting case scenarios.

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Coronary CTA

  1. 1. Coronary CTA. August 23, 2014. POOL SOCIETY WEEKEND JAYANTH H KESHAVAMURTHY, M.D. ASSISTANT PROFESSOR OF RADIOLOGY GEORGIA REGENTS UNIVERSITY.
  2. 2. 1. Question  An overweight man had CAC SCORE OF 500 last year. He has made significant life style changes since that time. He is now requesting a reevalauation of his cardiovascular risk. What would you recommend?  A. Coronary CTA with CAC score.  B. Coronary CTA without CAC score.  C. CAC score only.  D. Neither Coronary CTA nor CAC score.
  3. 3. Answer D.
  4. 4. TECHNIQUE  Prospective ECG triggered.  120kVP  Slice Collimation 2.5 -3mm.  Medium sharp reconstruction kernel without edge enhancement- provides moderate image noise.
  5. 5. TECHNIQUE  Z axis from carina to base of heart.  FOV is 250 mm.
  6. 6. INDICATIONS  Risk stratification in asymptomatic individual.  With intermediate Framingham Risk Score.
  7. 7. USEFULNESS  Incremental prognostic information.  Independent risk assessment over Framingham risk evaluation alone in patients without established CAD.
  8. 8. How is it calcium score calculated?  Agatston score is widely used.  It is area based.  Others have used volume and mass
  9. 9.  Coronary calcification is pathognomonic of atherosclerosis and represents an attempt at healing.
  10. 10.  Typically pixels with >130 HU (?90HU )are considered to represent calcification.  Area of the lesion is multiplied by a coefficient.(1-4).  Agatston scores of all lesions are summarized to yield the total Agatston scores per vessel and per patient.
  11. 11. FALLACY  Does not detect non-calcified atherosclerotic plaque.  Cannot accurately assess presence or absence of CAD.  Gives a crude estimate of atherosclerotic burden.
  12. 12.  CC Scores are lower in African American men than in Caucasian men.  Interscan reproducibilty is substantially better for high calcium scores.  Interscan variability is rather high. So follow up testing is not recommended.
  13. 13.  Calculate calcium score from CCTA from dual energy in future.  Using iterative reconstruction to reduce dose in future.
  14. 14. 2
  15. 15. 2. Regarding contrast protocol for performing pulmonary vein imaging which one of the following is true.  A. Identical to coronary CTA.  B. Requires higher contrast flow rates.  C. Bolus tracker should be placed at level of left atrium.  D. One should not consider using prospectively ECG triggered CT.
  16. 16. C. Bolus tracker should be placed at level of left atrium.
  17. 17. TECHNIQUE  Prospective or retrospective ECG gated study .  ROI is left atrium.  No beta blocker needed as we are not assessing coronary arteries.  Patient frequently in A.fib.
  18. 18. ASSESSMENT  LA size.  Anatomy of pulmonary veins- numbers, variations.  Ostial size is measured in Mid diastole to guide catheter sizes for EP ablation. Measured 1 cm from ostia in orthogonal reconstructed view.  LAA thrombus vs mixing artefact is differentiated by repeat CT 45-60 seconds later.  Relationship to esophagus- VR image provided.
  19. 19. VARIATIONS  LA Area – 11- 33 cm2.  Normal 2 left and 2 right PV.  Variations- 1 (common) left and 2 right PV. -2 left and 3 right PV ( separate ostia for middle lobe.)
  20. 20. COMPLICATIONS  PV Stenosis.  Esophageal perforation.  Cardiac tamponade.  Throbo-embolism.  Phrenic nerve injury.
  21. 21. 3
  22. 22. 3. All the following are coronary veins except A. Small cardiac vein. B. Middle cardiac vein. C. Large cardiac vein. D. Great cardiac vein.
  23. 23. C. Large cardiac vein.
  24. 24. CORONARY VEINS
  25. 25. TECHNIQUE Images are obtained 5-10 sec delay after ROI on aorta to allow for coronary venous return.
  26. 26. IMPORTANCE  To look for variations and assist in EP procedures like BIVICD Placement.  Also not to falsely confuse a vein as a patent coronary artery.
  27. 27. 4
  28. 28. What is the diagnosis?
  29. 29. 4. Question. What is the diagnosis? A. Coronary aneurysm. B. Coronary ectasia. C. Coronary fistula. D. Coronary dissection
  30. 30. B. Coronary ectasia.
  31. 31. 5
  32. 32. 5. What is the diagnosis? A. Hyper trophic cardiomyopathy. B. Non Compaction syndrome. C. Arrhythmogenic RV dysplasia. D. Ebsteins anomaly.
  33. 33. C. Arrhythmogenic RV dysplasia.
  34. 34. •Right ventricular dysfunction • Severe dilatation and reduction of RV ejection fraction with little or no LV impairment • Localized RV aneurysms • Severe segmental dilatation of the RV •Tissue characterization • Fibrofatty replacement of myocardium on endomyocardial biopsy •Conduction abnormalities • Epsilon waves in V1 - V3. • Localized prolongation (>110 ms) of QRS in V1 - V3 •Family history Major Criteria
  35. 35. •Right ventricular dysfunction • Mild global RV dilatation and/or reduced ejection fraction with normal LV. • Mild segmental dilatation of the RV • Regional RV hypokinesis •Tissue characterization •Conduction abnormalities • Inverted T waves in V2 and V3 in an individual over 12 years old, in the absence of a right bundle branch block (RBBB) • Late potentials on signal averaged EKG. • Ventricular tachycardia with a left bundle branch block (LBBB) morphology • Frequent PVCs (> 1000 PVCs / 24 hours) •Family history • Family history of sudden cardiac death before age 35 Minor Criteria
  36. 36. ARVD diagnostic criteria  There is no pathognomonic feature of ARVD. The diagnosis of ARVD is based on a combination of major and minor criteria.  To make a diagnosis of ARVD requires either 2 major criteria or  1 major and 2 minor criteria or  4 minor criteria.
  37. 37. ARVD  Genetic Cardiomyopathy.  Fibro fatty replacement of RV myocardium.  LBBB  Autosomal dominant with incomplete penetrance and autosomal recessive inheritance.  Positive family history in 30-50%.
  38. 38. 6
  39. 39. 6.Visibility of stent lumen depends on all of the following except A. Scanner technology. B. Stent size. C. Stent length. D. Stent lumen.
  40. 40. C. Stent length.
  41. 41.  RCA STENT SHARP FILTER  RCA STENT MEDIUM FILTER
  42. 42. 7
  43. 43. 7.What is the diagnosis? A. Transposition of great vessels. B. Truncus arteriosus. C. Coarctation of aorta. D. Tetralogy of Fallot.
  44. 44. D. Tetralogy of Fallot with ASD and Cor triatrium.
  45. 45. 8.
  46. 46. 8.What syndrome does this patient have? A. Downs syndrome. B. Tuberous sclerosis. C. Von Hippel landau disease. D. Turners syndrome.
  47. 47. B. Tuberous sclerosis.
  48. 48. 9
  49. 49. 9.Patient with history of recent stroke. A. Atrial thrombus. B. LV thrombus. C. Aortic dissection. D. Pulmonary embolism and ASD.
  50. 50. ANSWER B. LV THROMBUS
  51. 51.  
  52. 52. 10
  53. 53. 10.What is the diagnosis? A. Left atrial thrombus. B. Left atrial myxoma. C. left atrial lipoma. D. Atrial septal aneurysm.
  54. 54. B. Left atrial myxoma.
  55. 55. 11
  56. 56. 11. Using bolus tracking which is ideal attenuation threshold for performing coronary CTA.  LOCATION THRESHOLD A. Descending Aorta 400 HU B. Ascending Aorta 300 HU C. Descending Aorta 350 HU D. Ascending Aorta 150 HU
  57. 57. D. Ascending Aorta 150 HU
  58. 58. 12
  59. 59. 12. Second most common cause of sudden death? A. Hypertrophic cardiomyopathy. B. Anomalous origin and course of coronary arteries. C. Arrhythmia. D. Coronary dissection.
  60. 60. B. Anomalous origin and course of coronary arteries.
  61. 61. 13
  62. 62. 13.“Triple rule out”- simultaneous opacification of coronaries, aorta and pulmonary artery? A. Faster contrast injection rate. B. Larger contrast volume. C. Higher tube current. D. Thicker slice collimation.
  63. 63. B. Larger contrast volume.
  64. 64. 14
  65. 65. 14. Patient has had CABG, LIMA to LAD and SVG to OM. All the following are true regarding coronary CTA except A. CCTA has poor accuracy in assessing disease within bypass grafts. B. Radiation exposure is higher than in a CTA evaluating native vessels. C. His native coronaries will likely be heavily calcified which may potentially limit diagnostic accuracy. D. Routine surveillance of bypass graft patency in asymptomatic is not considered appropriate.
  66. 66. A. CCTA has poor accuracy in assessing disease within bypass grafts.
  67. 67. Curved MPR Straight MPR
  68. 68. 15
  69. 69. 15. What does this 87 year female have? A. Coronary artery fistula. B. Coronary artery dissection. C. Coronary artery aneurysm. D. Coronary artery ectasia.
  70. 70. A. Coronary artery fistula.
  71. 71. 16
  72. 72. 16. Name the artery arising from circumflex coronary artery. Study performed prior to RF ablation. A. S shaped SA nodal artery. B. Obtuse marginal artery. C. AV nodal artery. D. Acute marginal artery.
  73. 73. 17
  74. 74. 17. Name the anomalous artery. A. RCA. B. LAD. C. Circumflex coronary artery. D. SA nodal artery.
  75. 75. ANSWER C. Circumflex of RCA
  76. 76. 18
  77. 77. 18. Name the anomalous artery. A. RCA. B. LAD. C. Circumflex coronary artery. D. SA nodal artery.
  78. 78. ANSWER  C. Circumflex artery of right cusp separate ostia.
  79. 79. 19
  80. 80. 19. What is a common pitch for a typical coronary CT angiogram using retrospectively ECG-gated 64 – slice CT. A. 0.1 B. 0.2 C.1.0 D. 2.0
  81. 81. B. 0.2
  82. 82. 20
  83. 83. 20. What surgery did this patient have? A. ASD closure device. B. Mitral valve replacement. C. LA appendage clip. D. Tricuspid valve replacement.
  84. 84. A. Amplatz ASD occlusion device.
  85. 85. Thanks to  Dr. William Bates MD.  Dr. Benett Greenspan MD.  Dr. Gyanendra Sharma MD.

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