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Technical Innovation |
1
Department of Clinical Radiology, Ludwig-Maximilians-University Munich,
Klinikum Grosshadern, Marchioninistr. 15, D-81377 Munich, Germany.
2
Department of Cardiology, Ludwig-Maximilians-University Munich, D-81377
Munich, Germany.
3
Siemens Medical Systems, Siemens CTC5, Siemensstr. 1, D-91301 Forchheim,
Germany.
Received October 6, 1999;
accepted after revision January 6, 2000.
Address correspondence to C. R. Becker.
Introduction
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The day before the planned catheterization, a trial was undertaken to detect coronary artery calcifications and to noninvasively image the coronary arteries with CT. For this purpose, a fifth-generation multislice helical CT scanner (Somatom Plus4 VolumeZoom; Siemens, Forchheim, Germany) with four detector banks was used. For the detection of coronary artery calcifications, the entire heart was covered with 12 unenhanced scans. With each scan, four 2.5-mm slices were acquired using prospective ECG triggering at 450 msec before the next estimated R wave. These images did not reveal any calcifications in the coronary artery tree.
For CT coronary angiography, 140 mL of nonionic contrast material was administered through a peripheral vein. A helical scan was performed, simultaneously acquiring four 1-mm slices with every 500-msec rotation. The scan was started 25 sec after commencing contrast injection. During the scan, the patient had to hold his breath for 35 sec. The ECG signal was digitally recorded simultaneously to the scan acquisition. The acquired raw data were then reconstructed into 220 axial CT images of the heart. With the ECG trace, each image could be reconstructed at the identical time point of the cardiac cycle, 500 msec before the next R wave, with an effective exposure time of 250 msec for each section. This way, a motion free-image data set of the entire heart at a time point during end diastole could be generated.
For visualization of the entire data set, maximum intensity projection and volume rendering techniques were used, with a dedicated three-dimensional workstation (InSight; Neo Imagery Technologies, City of Industry, CA).
The cross-sectional maximum intensity projection of the lumen of the left anterior descending artery and the first diagonal branch revealed a high degree of vessel obstruction by a soft-tissue mass with a mean density of 30 H. Three-dimensional reconstruction with volume rendering technique confirmed the high-grade stenosis of these two vessels, whereas the right coronary artery showed normal lumen diameters. The findings of a proximal high-grade stenosis of the left anterior descending artery with involvement of the first diagonal branch were confirmed by conventional coronary angiography the following day (Fig. 1A,1B,1C,1D). The patient was successfully treated with balloon angioplasty and stenting of the stenotic segments.
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Absence of coronary calcification on CT has a high negative predictive value to exclude coronary artery disease in patients with atypical chest pain [1]. Nevertheless, in about 5-10% of the patients, coronary artery disease is present despite the absence of coronary calcifications, as in the patient presented here. In the past, noninvasive angiography has been performed with electron beam CT [2] and nuclear MR imaging [3]. Also, retrospective ECG gating of a helical CT data set from a conventional single-detector CT scanner has been proposed to allow for quantification of coronary artery calcifications [4]. For the first time, however, retrospective ECG-gated reconstruction of a multislice helical CT data set was used to produce motion-free images of contrast-enhanced coronary arteries.
With a temporal resolution of 250 msec per image, this method presently is most effective for patients with a heart rate of less than 70 beats per minute. The high spatial resolution, the low image noise, and the high tissue contrast are superior to those of any other imaging technique. Unlike other techniques that are currently used for noninvasive coronary angiography, multislice CT enables the radiologist to detect noncalcified plaques of the coronary arteries. Further studies are warranted to define the potential role of this method in the noninvasive workup of patients with known or suspected coronary artery disease.
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