August 23, 2014.
POOL SOCIETY WEEKEND
JAYANTH H KESHAVAMURTHY, M.D.
ASSISTANT PROFESSOR OF RADIOLOGY
GEORGIA REGENTS UNIVERSITY.
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.
Z axis from carina to base of heart.
FOV is 250 mm.
Risk stratification in asymptomatic individual.
With intermediate Framingham Risk Score.
Incremental prognostic information.
Independent risk assessment over
Framingham risk evaluation alone in patients
without established CAD.
How is it calcium score calculated?
Agatston score is widely used.
It is area based.
Others have used volume and mass
Coronary calcification is pathognomonic of
atherosclerosis and represents an attempt at
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.
Does not detect non-calcified atherosclerotic
Cannot accurately assess presence or absence
Gives a crude estimate of atherosclerotic
CC Scores are lower in African American men than in
Interscan reproducibilty is substantially better for high
Interscan variability is rather high. So follow up testing is
Calculate calcium score from CCTA from dual energy in
Using iterative reconstruction to reduce dose in future.
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
D. One should not consider using prospectively
ECG triggered CT.
C. Bolus tracker should be placed
at level of left atrium.
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.
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.
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.)
•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
• Fibrofatty replacement of myocardium on
• Epsilon waves in V1 - V3.
• Localized prolongation (>110 ms) of QRS in V1 - V3
•Right ventricular dysfunction
• Mild global RV dilatation and/or reduced ejection
fraction with normal LV.
• Mild segmental dilatation of the RV
• Regional RV hypokinesis
• Inverted T waves in V2 and V3 in an individual over 12
years old, in the absence of a right bundle branch
• Late potentials on signal averaged EKG.
• Ventricular tachycardia with a left bundle branch
block (LBBB) morphology
• Frequent PVCs (> 1000 PVCs / 24 hours)
• Family history of sudden cardiac death before age 35
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.
Fibro fatty replacement of RV myocardium.
Autosomal dominant with incomplete
penetrance and autosomal recessive
Positive family history in 30-50%.
11. Using bolus tracking which is ideal
attenuation threshold for performing
A. Descending Aorta 400 HU
B. Ascending Aorta 300 HU
C. Descending Aorta 350 HU
D. Ascending Aorta 150 HU
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
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.
A. CCTA has poor accuracy in
assessing disease within bypass
16. Name the artery arising from circumflex
coronary artery. Study performed prior to
A. S shaped SA nodal artery.
B. Obtuse marginal artery.
C. AV nodal artery.
D. Acute marginal artery.