HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text Full Text (PDF) CME Animations Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Tsai, I-C. Articles by Liao, W.-C. Search for Related Content PubMed PubMed Citation Articles by Tsai, I-C. Articles by Liao, W.-C. Social Bookmarking                      What's this? Hotlight (NEW!) What's Hotlight?

Comprehensive Evaluation of Ischemic Heart Disease Using MDCT

¹ Department of Radiology, 407, Taichung Veterans General Hospital, No. 160, Section 3, Taichung Harbor Rd., Taichung, Taiwan, ROC.
² Faculty of Medicine, Medical College of Chung Shan Medical University, Taiwan, ROC.
³ Department of Medicine, National Yang Ming University, Taiwan, ROC.
⁴ Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming University, Taiwan, ROC.
⁵ Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan, ROC.

View larger version (116K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —63-year-old man with chronically occluded coronary stent over left anterior descending artery and infarcted myocardium. This case shows importance of comprehensive evaluation of cardiac CT. Multiplanar reformatted image of coronary arteries shows coronary stent over middle portion of left anterior descending artery (arrow). Because this is maximum-intensity-projection image, intrastent assessment is blocked by stent itself.

View larger version (49K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —63-year-old man with chronically occluded coronary stent over left anterior descending artery and infarcted myocardium. This case shows importance of comprehensive evaluation of cardiac CT. Thin-section (0.4 mm) multiplanar reformation for intraluminal assessment shows multiple low-density regions (arrows) inside stent, indicating intrastent occlusion.

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —63-year-old man with chronically occluded coronary stent over left anterior descending artery and infarcted myocardium. This case shows importance of comprehensive evaluation of cardiac CT. Short-axis image of diastole in arterial phase shows decreased perfusion and myocardial thinning over anteroseptal wall (between arrows) compared with remote myocardium (arrowheads). Cine imaging is provided in Figure S1C in supplemental data online.

View larger version (115K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D —63-year-old man with chronically occluded coronary stent over left anterior descending artery and infarcted myocardium. This case shows importance of comprehensive evaluation of cardiac CT. Short-axis image of systole in arterial phase also shows decreased perfusion and myocardial thinning over anteroseptal wall (between arrows) compared with remote myocardium (arrowheads). Anteroseptal wall also shows akinesia if compared with C. Note that in systole, differentiating trabeculation, papillary muscle, and myocardium is difficult.

View larger version (141K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1E —63-year-old man with chronically occluded coronary stent over left anterior descending artery and infarcted myocardium. This case shows importance of comprehensive evaluation of cardiac CT. Short-axis image of 6-minute delayed phase image shows persistent perfusion defect and peripheral delayed hyperenhancement in anteroseptal wall (between arrows), indicating extensive myocardial infarction in territory of left anterior descending artery. Note remote viable myocardium shows normal washout pattern (arrowhead).

View larger version (144K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1F —63-year-old man with chronically occluded coronary stent over left anterior descending artery and infarcted myocardium. This case shows importance of comprehensive evaluation of cardiac CT. Horizontal long-axis image during delayed phase shows thrombus (white arrow) in left ventricular apex. In arterial phase, it is sometimes difficult to differentiate between left ventricular myocardium and firmly attached mural thrombus. But in delayed phase, because of different contrast medium washout pattern, thrombus (white arrow) is easily differentiated from normal viable myocardium (black arrow). Due to lack of blood supply, the thrombus (white arrow) would present like the `microvascular obstruction' myocardium (arrowhead), as delayed perfusion defect. But the thrombus would protrude into the left ventricular cavity, and the delayed defect is located within the myocardium.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —68-year-old man with acute myocardial infarction. This case shows importance of comprehensive evaluation in cardiac CT. Multiplanar formatted image shows obstruction of distal circumflex artery (arrows) and faint enhancement of terminal branch (arrowheads). It is important to recognize this pattern because inexperienced radiologists or technologists might fail to track entire distal circumflex artery and misinterpret this as a shorter circumflex artery ending at asterisk.

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —68-year-old man with acute myocardial infarction. This case shows importance of comprehensive evaluation in cardiac CT. Short-axis image during diastole in arterial phase shows decreased perfusion over infralateral wall (between arrows) involving posterior papillary muscles (black arrowhead). Compare density of anterior (white arrowhead) and posterior (black arrowhead) papillary muscle. Involvement of infralateral wall and posterior papillary muscle is prognostic of ischemic mitral regurgitation. See also cine image, Figure S2B, in supplemental data online.

View larger version (133K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —68-year-old man with acute myocardial infarction. This case shows importance of comprehensive evaluation in cardiac CT. Short-axis image during systole in arterial phase shows decreased perfusion over infralateral wall (between arrows), involving posterior papillary muscle (black arrowhead). In regions with normal systolic wall motion, papillary muscle and compact myocardium are difficult to differentiate because contrast medium between them is squeezed out (white arrowhead). But in akinetic region (between arrows), it is still possible to identify papillary muscle (black arrowhead).

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2D —68-year-old man with acute myocardial infarction. This case shows importance of comprehensive evaluation in cardiac CT. Short-axis image during delayed phase shows delayed perfusion defect over subendocardium of infralateral wall (between arrows) and papillary muscle (arrowhead). Note that delayed defect in this phase is slightly smaller than perfusion defect in arterial phase. Difference between the two indicates ischemic penumbra, which is potentially salvageable by emergent percutaneous coronary intervention.

View larger version (159K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2E —68-year-old man with acute myocardial infarction. This case shows importance of comprehensive evaluation in cardiac CT. Coronary angiography image shows exactly same coronary findings as MDCT; asterisk, arrows, and arrowheads are placed in corresponding places to those in A. Wire indicates course of circumflex artery. See also cine image, Fig. S2E.

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —51-year-old man with low calcium score (9.7) who nevertheless has lesion over left anterior descending coronary artery, which is almost totally occluded. Multiplanar reformatted image shows near-total occlusion over middle portion of left anterior descending coronary artery (white arrow). Note small calcified spot (black arrow), which was calculated as Agatston calcium score of only 9.7.

View larger version (152K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —51-year-old man with low calcium score (9.7) who nevertheless has lesion over left anterior descending coronary artery, which is almost totally occluded. Catheter coronary angiography image shows middle left anterior descending coronary artery lesion (arrow) exactly the same as on MDCT. Lesion was treated with stent implantation.

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —11-year-old boy with history of Kawasaki disease. Volume-rendering image shows chronically occluded proximal right coronary artery (RCA) and good collateral formation (arrows) from distal left anterior descending artery (LAD) to acute marginal branch (AM) of RCA. In clinical practice, collateral arteries are usually smaller than resolution of current MDCT technology. Also, location is usually intramyocardial, which would be difficult to discern because of lack of contrast resolution between collateral vessels and enhanced myocardium. This collateral (arrows) is well shown because it is a single large epicardial collateral vessel.

View larger version (154K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —11-year-old boy with history of Kawasaki disease. Multiplanar reformatted image also confirms collateral (white arrows) between distal LAD and AM of RCA. Also note chronically occluded proximal right coronary artery (arrowheads). Dashed portion (black arrow) of collateral is caused by software reconstruction problem. Dashed segment is actually good and patent in both source images (not shown) and volume-rendering images (A).

View larger version (110K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —77-year-old man with cor pulmonale and suspected diastolic dysfunction of left ventricle (LV). Reconstructed large-field-of-view image from original cardiac CT data set shows emphysematous change in both lungs and destroyed right lower lobe (arrow) due to tuberculosis. Also note, there is no acoustic window for echocardiographic assessment. Window is blocked either by sternum or by emphysematous lungs.

View larger version (146K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —77-year-old man with cor pulmonale and suspected diastolic dysfunction of left ventricle (LV). Four-chamber view shows dilated right ventricle (white double arrow), especially when compared with left ventricle (black double arrow). Cine image of four-chamber view is provided as Figure S5B in supplemental data online.

View larger version (11K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5C —77-year-old man with cor pulmonale and suspected diastolic dysfunction of left ventricle (LV). Blood volume-versus-cardiac phase plot shows slow filling (arrows) in early diastole (passive filling phase) and fast filling (arrowheads) in late diastole (atrial kick phase), which indicate diastolic dysfunction. Cardiac motion in short axis is shown in Figure S5C in supplemental data.

View larger version (11K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5D —77-year-old man with cor pulmonale and suspected diastolic dysfunction of left ventricle (LV). For comparison, note this blood volume-versus-cardiac phase plot in another patient of similar age (77 vs 76 years old) and ejection fraction (60.1% vs 62.3%) shows normal diastolic curve, fast passive filling (arrows), and slow atrial kick (arrowheads). Cardiac motion in short axis is shown in cine image, Figure S5D, in supplemental data.

View larger version (142K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —Valvular disease related to ischemic heart disease. 56-year-old man with ischemic heart disease and left ventricular remodeling and dilatation. This mitral view during end-systole is created to align anterior papillary muscle, chordae tendineae, and both leaflets of mitral valve in same plane. Because of left ventricular dilatation, posterior displaced papillary muscle is pulling tendineae (arrows), which subsequently causes mitral tethering, with an angle between proximal and distal anterior leaflets of mitral valve (dashed line). This condition leads to poor coaptation between the two leaflets of the mitral valve, and mitral regurgitation is expected. In cine image, Figure S6A in supplemental data online, rigid and limited motion of mitral valve can be clearly visualized. Echocardiography then confirmed severe mitral regurgitation. Mitral annuloplasty was performed.

View larger version (142K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —Valvular disease related to ischemic heart disease. End-systole mitral view of postoperative cardiac CT in same patient as in A shows disappearance of angle (dashed line) and good coaptation. With reduction of diameter of mitral annulus by mitral ring (black arrow), chordae tendineae (white arrows) no longer tether anterior leaflet of mitral valve. In cine image, Figure S6B, good motion of mitral valve is seen. This case shows that MDCT can be used even in visualizing valves and chordae tendineae.

View larger version (138K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6C —Valvular disease related to ischemic heart disease. 21-year-old woman with exertional dyspnea who is suspected of having ischemic heart disease. Routine three-chamber view shows thickening and poor coaptation of aortic valve (arrow). When aortic valve looks somewhat unusual, further evaluation focusing on aortic valve should be undertaken. Cine animation in three-chamber view is provided as Figure S6C in supplemental data.

View larger version (160K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6D —Valvular disease related to ischemic heart disease. Virtual angioscopic image in same patient as in C shows fusion (arrows) of commissures between noncoronary (N) and right coronary (R) cuspids and between noncoronary (N) and left coronary (L) cuspids. Only commissure between left (L) and right (R) coronary cuspids could fully open (arrowhead). Unicuspid aortic valve was diagnosed. At echocardiography, severe aortic regurgitation and moderate aortic stenosis were found, which indicated need for valve replacement surgery.

View larger version (184K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6E —Valvular disease related to ischemic heart disease. Excised aortic valve in same patient as in C shows exactly same findings as MDCT. Annotations in this image are same as in D. In this case, if MDCT interpretation had included only CT coronary angiography, diagnosis could have been delayed until an experienced echocardiographer found unicuspid aortic valve and accompanying aortic stenosis and regurgitation.

View larger version (163K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —Diseases presenting with symptoms of ischemic heart disease that can be diagnosed by comprehensive evaluation with MDCT. Sternal dehiscence in 76-year-old man after coronary bypass surgery with recurrent symptoms after 1 month. Volume-rendering image shows nonunion of sternum and sternal dehiscence. Bypass grafts and distal native coronary arteries are patent.

View larger version (143K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —Diseases presenting with symptoms of ischemic heart disease that can be diagnosed by comprehensive evaluation with MDCT. Midventricular hypertrophic obstructive cardiomyopathy in 72-year-old woman with exertional dyspnea. Horizontal long-axis image during end-systole shows "kissing" of midventricular myocardium and lumen obliteration (arrow), making only basal heart an effective chamber. Cine animation is provided as Figure S7B in supplemental data online.

View larger version (97K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7C —Diseases presenting with symptoms of ischemic heart disease that can be diagnosed by comprehensive evaluation with MDCT. Echocardiographic images of same patient as in B show diagnosis cannot be established by echocardiography. Hypoechoic presentation of hypertrophied myocardium makes it impossible to differentiate hypertrophied myocardium from left ventricular cavity. If only CT coronary angiography is interpreted, patient's diagnosis might be delayed until cardiac MRI or catheter left ventriculography is performed. S = systole, D = diastole.

View larger version (136K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7D —Diseases presenting with symptoms of ischemic heart disease that can be diagnosed by comprehensive evaluation with MDCT. Lupus microangiopathy in 42-year-old woman who presented with exertional dyspnea. Previous nuclear perfusion scan shows marked decreased perfusion over lateral wall of left ventricle. Multiplanar reformatted image shows normal coronary arteries. But decreased attenuation over lateral wall (arrows) and normal obtuse marginal branches seem somewhat unusual. CRX = circumflex artery, LAD = left anterior descending coronary artery, RCA = right coronary artery.

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7E —Diseases presenting with symptoms of ischemic heart disease that can be diagnosed by comprehensive evaluation with MDCT. Delayed phase image of same patient as in D shows infarction over lateral wall (arrow). Akinetic motion and muscle thinning over corresponding region are shown in cine image, Figure S7E, in supplemental data. Because overlying coronary artery is normal, infarction is considered to be related to capillary damage due to lupus activity. If only coronary arteries are interpreted, patient's diagnoses might be delayed until cardiac MRI and catheter coronary angiography are performed. Precise match to exclude possibility of one totally obstructed obtuse marginal branch can only be done with MDCT because of its ability to simultaneously visualize coronary arteries and myocardium.

View larger version (114K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7F —Diseases presenting with symptoms of ischemic heart disease that can be diagnosed by comprehensive evaluation with MDCT. Pulmonary artery compressing left main coronary artery. A 36-year-old man presented with exertional dyspnea and was found to have atrial septal defect later. After placement of Amplatz septal occluder (ASO), symptoms persisted. MDCT was performed 2 days later. Multiplanar reformatted image shows left main coronary artery (arrow) is critically compressed by dilated pulmonary artery because of long-term atrial septal defect. Because pulmonary artery is expected to shrink after closure of atrial septal defect, follow-up is suggested. After discharge, patient's symptoms gradually subsided over 3 months. RPA = right pulmonary artery, MPA = main pulmonary artery, RV = right ventricle, LV = left ventricle.

CiteULike

Complore

Connotea

Del.icio.us

Digg

Reddit

Technorati