Lecture vienna september 16 2005
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This document summarizes the use of noninvasive MDCT imaging of the coronary arteries. It discusses the challenges of imaging small, rapidly moving coronary vessels. MDCT allows for successful coronary imaging with temporal resolution of 330-400ms, spatial resolution of 0.4-0.75mm, coverage of the heart in a single breath hold of 8-14 seconds. Sensitivity for detecting coronary stenosis is 80-86% for 4-16 slice MDCT and specificity is 90-97%. Potential clinical applications include decreasing invasive angiograms, improving risk assessment, detecting anomalies, and evaluating bypass grafts. Larger clinical trials are still needed to determine the impact on patient management.
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Coronary angiography
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Editorial v2n7
I. Real-time MR-guided stent placement is now feasible in coronary arteries of pigs. The presented real-time MR imaging sequence allows for high-quality coronary MR fluoroscopy without cardiac motion artifacts.
II. Passive visualization of the guidewire and stent during the procedure is sufficient for real-time monitoring.
III. While MR guidance has advantages over x-ray for interventional cardiology like reduced radiation and better imaging, challenges remain from respiratory and cardiac motion artifacts and the small, tortuous anatomy of coronary arteries.
Ischemic heart diseases 2
1) Ischemic heart disease results from an imbalance between the heart's demand for oxygenated blood and the supply delivered by the coronary arteries, usually due to atherosclerotic plaque buildup.
2) It manifests as stable angina, unstable angina, myocardial infarction, or sudden cardiac death.
3) Myocardial infarction occurs when a blockage in a coronary artery results in prolonged ischemia and cell death in the heart muscle.
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This field can be divided into two broad areas – DIAGNOSTIC RADIOLOGY & INTERVENTIONAL RADIOLOGY.
A medical doctor who specializes in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays, computed tomography (CT), etc.
The most common types of diagnostic radiology exams include :
X-ray Radiography,
Ultrasound,
Computed Tomography (CT),
Nuclear Medicine Including Positron Emission Tomography (PET), And
Magnetic Resonance Imaging (MRI)
x-rays
Cardiac MRI
Myocardial viability testing is important in patients with coronary disease and severely reduced left ventricular systolic function to determine whether revascularization may improve outcomes by identifying dysfunctional but still viable myocardium. Revascularization of viable myocardium can help recover function and symptoms, whereas predominantly scarred myocardium will not benefit from revascularization.
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A detailed description of ct coronary angiography and calcium scoring with various aspects regarding the preparation, procedure, limitations and a short review regarding post CABG imaging.
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This document discusses intravascular ultrasound elastography (IVUS), a technique that measures the elastic properties and stiffness of vessel walls and atherosclerotic plaque. It can identify soft, lipid-rich plaques that are more vulnerable to rupture compared to hard, calcified plaques. The document summarizes a study that found IVUS elastography could successfully identify fatty plaques in vivo in an atherosclerotic pig model, with 100% sensitivity and 80% specificity. The study also showed this technique had high sensitivity and specificity for identifying lipid and macrophages within plaques. However, questions remain about how it can detect plaque inflammation and what normal and abnormal elasticity values mean clinically.
19 cardiac anatomy and Imaging techniques Dr. Muhammad Bin Zulfiqar
This is a chapter from Grainger and Allison. I have Coolected all images from chapter 19 with caption in this presentation.
In my opinion it will be very benificial to have this in your android. ,
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19 cardiac anatomy and Imaging techniques Dr. Muhammad Bin Zulfiqar
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This document discusses the promises and limitations of fast CT angiography for coronary artery imaging. It summarizes that CT techniques have improved over time, with multislice spiral CT now able to acquire images with high spatial resolution and good contrast in less than 500 ms. However, temporal resolution remains a challenge, especially at higher heart rates. CT coronary angiography has high negative predictive value for ruling out significant stenoses when image quality is sufficient, but it cannot replace cardiac catheterization and has limitations for patients with arrhythmias or unevaluable arteries. The detection of coronary plaque is also discussed as a potential role for CT, but accuracy and reproducibility require further study.
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This document discusses the promises and limitations of fast CT angiography for coronary artery imaging. It summarizes that CT techniques have improved over time, with multislice spiral CT now able to acquire images with high spatial resolution and good contrast in less than 500 ms. However, temporal resolution remains a challenge, especially at higher heart rates. CT coronary angiography has high negative predictive value for ruling out significant stenoses when image quality is sufficient, but it cannot replace cardiac catheterization and has limitations for patients with arrhythmias or unevaluable arteries. The detection of coronary plaque is also discussed as a potential role for CT, but accuracy and reproducibility require further study.
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Fu Q - AIMRADIAL 2014 - Left vs right radial approach
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1) The document describes two studies comparing the left radial approach (LRA) and right radial approach (RRA) for coronary angiography and primary PCI in Chinese patients.
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CT coronary angiography can provide detailed images of the coronary arteries. It has high temporal and spatial resolution allowing visualization of small coronary arteries. The technique uses ECG gating and retrospective reconstruction to achieve motion-free images. Various pathologies like stenosis, anomalies, plaques and bypass grafts can be evaluated. Image quality can be affected by artifacts from calcium, stents or irregular heart rates.
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This document discusses triggers for sudden cardiac arrest (SCA) and death (SCD). It notes that over 2/3 of SCD cases are unable to be predicted due to a lack of well-established risk factors. While population risk factors can identify at-risk groups, they cannot predict risk for individuals. The document explores various biological, anatomical, and environmental factors that can precipitate fatal arrhythmias and discusses how the timing of transient initiating events is critical for the development of ventricular tachyarrhythmias. It emphasizes that myocardial electrophysiological processes likely determine the onset or lack of VT/VF/SCD and that immediate access to automated external defibrillators is needed to save lives.
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The document discusses vulnerable plaque and challenges in detecting and treating it. It describes various imaging techniques for detecting vulnerable plaque such as thermography, MRI, CT angiography, and optical coherence tomography. However, it notes that while these can identify high-risk features, it remains unclear what exactly defines vulnerable plaque and whether imaging findings truly correlate with risk. The document also notes that while statins reduce events, the relationship between plaque burden and events is unclear, and better defining and detecting the disease is still needed before new therapies can be developed.
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1) The study examined 92 hearts from patients with severe coronary artery disease who died suddenly. The hearts were sectioned and plaque types were classified.
2) The number of "vulnerable" plaques, particularly thin cap atheromas, was highest in hearts of patients who died from acute plaque rupture and lowest in those with incidental disease.
3) Thin cap atheromas and other unstable plaque types were concentrated in the proximal coronary segments, similar to the distribution of plaque ruptures. The study suggests vulnerable plaques contribute to acute coronary syndromes and are non-uniformly distributed within the coronary arteries.
Vp watch editorial_slide 25short-
1) Drug-coated stents, particularly those coated with sirolimus, have shown promise in reducing restenosis compared to bare metal stents. Sirolimus inhibits cell proliferation and has been shown in studies to reduce intimal hyperplasia and restenosis in animal models by 50% or more.
2) A study by Suzuki et al. found that a sirolimus-coated stent reduced restenosis by 50% through inhibiting cellular proliferation in a dose-dependent manner compared to a bare metal stent. Adding dexamethasone to the coating did not provide additional benefit.
3) If results of the RAVEL clinical trial showing "zero" restenosis out to 5 years
Vp watch editorial_slide25
This document discusses drug-coated stents for preventing restenosis. It summarizes a study showing that stents coated with sirolimus via a polymer matrix reduced restenosis by 50% by inhibiting cell proliferation. Adding dexamethasone provided no additional benefit. Other studies also showed sirolimus inhibits smooth muscle cell proliferation. If results of the RAVEL trial showing "zero" restenosis at 210 days hold true long-term, sirolimus-coated stents may become the standard therapy for coronary revascularization. Questions are raised about whether coating vulnerable plaques could be a primary treatment and if multiple vulnerable plaques would all be stented.
Vp watch editorial_slide25short-
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Vp watch2002
I. This document discusses various animal models that have been used to study atherosclerosis and plaque rupture, including quail, pigeons, chickens, dogs, monkeys, pigs, rats, rabbits, and mice. It provides details on the types of lesions developed and similarities to human disease for each model.
II. The double knockout LDL/apoE mice are highlighted as offering improvements in studying clinical complications of atherosclerosis like human heart disease. However, it is unclear how closely they model vulnerable plaques.
III. Questions are raised about how closely the coagulation systems of these animal models resemble humans and whether any model fully captures repeated plaque ruptures and the role of aging in natural history as seen in humans.
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Trans-Blood Vision is a patented infrared technique that uses short-wave infrared wavelengths to see directly through blood. It has the potential to find vulnerable plaque lesions without first entering them, determine their size and surface characteristics in high resolution, and look at their material constituents both on and below the surface. While it cannot provide direct visual guidance for therapy or penetrate as deeply as ultrasound, combining it with augmentative technologies could allow for real-time multi-mode detection, analysis, and therapy guidance of vulnerable plaque lesions. The document concludes that Trans-Blood Vision warrants significant investigation, possibly in combination with other emerging technologies.
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Lecture vienna september 16 2005
- 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. Challenge of Coronary Artery Imaging Small Vessels with Complex Anatomy in Rapid Motion Cornerstone Invasive Selective Coronary Angiography
- 3. Prerequisites forPrerequisites for Successful Cardiac CTSuccessful Cardiac CT II • Temporal Resolution • Spatial Resolution • Volume Coverage
- 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. 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
- 8. Thin MIP 3D VRT Curved MPR Post Processing
- 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. Detection of significant coronary artery stenosis
- 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. 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%
- 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. Maximum Intensity Projection RCA 3D VRT LCX and RCA
- 20. Limitations TECHNICAL -- Calcium - Motion - Heart Rate CONCEPTUAL - Contrast, X-ray - Sinus rhythm - No intervention
- 21. - 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
- 22. Study Design early risk stratification in the ED decision to admit to hospital MDCT standard clinical care (blinded to MDCT) discharge diagnosis
- 23. 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
- 24. 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
- 25. • Patient with crushing chest pain • now relieved (Nitro) • Borderline ST- Elevation • No biomarker elevation Patient with ACSPatient with ACS
- 27. LAD Occlusion
- 30. LCX Anomaly and Stenosis
- 32. Perfusion Defect
- 35. 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
- 36. - 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
- 38. - 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
- 39. • High sensitivity and specificity for arterial conduits and venous grafts • Limitations: distal Anastomosis in small vessels, metallic clips Martuscelli Circulation 2004 Bypass Graft Patency
- 40. - 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
- 41. MPR of LAD in Cross SectionThin MIP Detection of Plaque Sensitivity 82%, Specificity 88% Achenbach et al. Circulation 2004
- 42. r = 0.64, p < 0.001 Moselewski et al. AJC 2004 Plaque Area Potential to detect and quantify coronary plaque
- 43. Plaque Composition Potential to discriminate calcified and non- calcified plaque Leber et al JACC
- 44. 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
- 45. 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