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1 Department of Internal Medicine II, Universität Erlangen-Nuernberg,
Ulmenweg 18, D-91054 Erlangen, Germany.
2 Institute of Diagnostic Radiology, Universität Erlangen-Nuernberg,
D-91054 Erlangen, Germany.
3 Institute of Medical Physics, Universität Erlangen-Nuernberg, D-91054
Erlangen, Germany.
Received February 20, 2002;
accepted after revision April 3, 2002.
Supported by a grant from the ELAN Program, University of
Erlangen-Nuernberg, Erlangen, Germany.
Abstract
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MATERIALS AND METHODS. In 100 patients, MDCT was performed, and ECG-gated cross-sectional images were retrospectively reconstructed. From the 10 data sets obtained for each patient (reconstructed at 0-90% of the cardiac cycle in increments of 10%), we chose the best data set for every coronary artery. The images of the arteries were evaluated for occurrence of artifacts and the presence of high-grade stenosis (diameter reduction exceeding 70%) or occlusions. MDCT results were compared with coronary angiographic findings.
RESULTS. Of the 400 coronary arteries, 115 (29%) could not be
evaluated because of motion artifacts (n = 84) or other reasons
(n = 31). Overall, 51 (49%) of 104 stenoses were revealed on MDCT.
For detecting stenosis in those arteries that we could evaluate, MDCT had a
sensitivity of 91% (51 of 56 stenoses detected) and a specificity of 89%. As
the heart rate increased, the number of arteries that could be evaluated
decreased, and overall sensitivity for stenosis detection decreased from 62%
(heart rate 
70 beats per minute) to 33% (heart rate > 70 beats per
minute).
CONCLUSION. MDCT can reveal coronary stenoses, but the usefulness of MDCT as an aid in accurately evaluating stenoses decreases as a patient's heart rate increases.
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Multidetector CT (MDCT)
MDCT was performed using a Somatom Volume Zoom scanner (Siemens, Forchheim,
Germany) according to a previously described protocol
[1]. Patients were examined in
the supine position, and all image acquisitions were performed during
inspiratory breath-hold. To reduce the heart rate, a ß-blocker (50 mg of
metoprolol) was administered orally 2 hr before the examination in the last 36
patients to provide comparison data between this group and the first 64
patients. After determining the contrast agent transit time
[1], we acquired MDCT data
during an IV injection of 160 mL of the iodinated contrast agent iopromid
(Ultravist 370; Schering, Berlin, Germany) at a rate of 4 mL/sec. The
following scanning protocol was used: collimation, 4 x 1 mm; gantry
rotation time, 500 msec; and table feed, 1.5 mm/rotation. The tube current was
150 mA at 140 kV to keep the radiation dose within a reasonable range. A delay
corresponding to the measured contrast agent transit time was kept between the
initiation of the contrast agent injection and the start of the acquisition.
The breath-hold time was between 30 and 40 sec, depending on the scanning
volume.
For image reconstruction, we processed the raw CT data on a separate workstation (ImpactIR; VAMP, Möhrendorf, Germany). Using retrospective ECG-gating and the 180° multislice cardiac interpolation algorithm [13], we reconstructed cross-sectional images with a slice thickness of 1.2-1.4 mm in 1-mm intervals to obtain image acquisition windows of 125-250 msec (full width at one-tenth maximum of the phase-contribution profile) [13], depending on a patient's heart rate [1]. The field of view was 180 mm with an image matrix of 512 x 512 pixels. For each patient, we created 10 data sets evenly spaced throughout the cardiac cycle (0-90% of the R wave—to—R wave interval). We inspected all data sets and, for each coronary artery, selected the data set that contained the fewest motion artifacts for further evaluation.
Using an off-line workstation (NetraMD; ScImage, Los Altos, CA), an independent reviewer who was unaware of the clinical condition or the invasive coronary angiographic findings of the patients evaluated the MDCT images. The coronary arteries were classified as "assessable" or "nonassessable" on the basis of the cross-sectional images, sliding thin-slab maximum intensity projections [16], multiplanar reconstructions, and three-dimensional reconstructions. The images of the arteries that could be assessed were examined for the presence of high-grade stenoses (diameter reduction exceeding 70%) and occlusions. Results were documented separately for the four major epicardial arteries (left main, left anterior descending, left circumflex, and right coronary artery). Side branches with a diameter equal to or greater than 2 mm were included in the analysis of the respective coronary artery (e.g., a stenosis detected in a diagonal branch would be documented as stenosis of the left anterior descending artery).
Quantitative Coronary Angiography
Coronary angiograms were obtained in all patients 1 to 3 days after MDCT.
Lesion severity was evaluated using a digital analysis system (Quant-Cor.QCA
version 2.0; Siemens) that was based on the Cardiovascular Angiography
Analysis System II (CAAS II; Pie Medical Imaging, Maastricht, The
Netherlands). The automated edge detection of the system has been validated
and described elsewhere [17,
18]. The tip of the 5-French
or 6-French angiography catheter was used as a calibration device. The luminal
edges were detected using a weighted sum of the first- and second-derivative
functions of the brightness profile perpendicular to the center line of the
vessel, and the vessel diameter was determined by computing the shortest
distance between the right and left contours. The percentage of diameter
stenosis and the interpolated reference diameter were averaged across two
orthogonal projections. Lesions with a mean diameter reduction of 70% or more
were considered high-grade stenoses. In addition, the reference diameter of
every lesion was documented because only lesions in vessel segments with a
lumen diameter of 2 mm or more were included in the analysis.
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The optimal position of the imaging window for clear visualization of the coronary arteries varied considerably from patient to patient (Table 1). Although the mid to late diastole cardiac phase frequently yielded the best image quality of left main, left anterior descending, and left circumflex arteries, the optimal position to clearly visualize the right coronary artery was more evenly distributed over late systole, early diastole, and mid to late diastole. The heart rate strongly influenced the optimal cardiac phase (Table 2). The best imaging window in patients with a heart rate of 70 beats/min or less was usually during mid to late diastole. Because of the shorter duration of diastolic relaxation, the optimal cardiac phase to visualize the coronary arteries in patients with a heart rate of more than 70 beats/min was more frequently during late systole and early diastole.
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Of 400 coronary arteries studied, 285 (71%) could be evaluated for the presence of occlusions or stenoses. In 39 patients (39%), all coronary arteries were assessable by MDCT. One hundred and fifteen (29%) of 400 coronary arteries were judged to be unassessable because of motion artifacts (84/115) or other reasons, such as severe calcification or incomplete breath-holding by the patient (31/115). The right coronary artery was more frequently affected by degraded image quality (48 patients) than were the other arteries (left main, 8 patients; left anterior descending, 24 patients; and left circumflex, 35 patients; p < 0.05). In the 60 patients with a heart rate of 70 beats/min or less, only 31 (13%) of 240 coronary arteries were affected by motion artifacts, whereas in the 40 patients with a heart rate of more than 70 beats/min, 53 (33%) of 160 arteries were degraded by motion artifacts (p < 0.001) (Figs. 1A,1B,1C,1D,2,3).
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MDCT revealed 51 (49%) of 104 high-grade stenoses (diameter reduction 
70%) and occlusions in the coronary arteries (including their side branches
with a diameter 2 mm). The overall sensitivity for stenosis detection in
assessable and nonassessable arteries decreased from 62% (36/58) in patients
with a heart rate of 70 beats/min or less to 33% (15/46) in patients with a
heart rate of more than 70 beats/min (p < 0.01)
(Table 3).
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In the 285 assessable coronary arteries, all 11 occlusions and 40 of 45
high-grade stenoses were correctly identified on MDCT (Figs.
4A,4B
and
5A,5B).
The only lesion present in the left main artery, 30 of the 33 lesions present
in the left anterior descending artery (including diagonal branches with
diameters 2 mm), seven of nine lesions present in the left circumflex
artery (including marginal branches with diameters of 2 mm), and all 13
lesions present in the right coronary artery were correctly detected. Four of
five false-negative findings of stenosis were located in diagonal or marginal
branches. The mean reference diameter of these vessel segments was 2.5
± 0.5 mm. One false-negative finding of stenosis was in the left
circumflex artery, and, retrospectively, this error was found to be caused by
calcifications.
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A total of 223 of the 229 assessable coronary arteries with no occlusion or stenosis were correctly judged to be free of obstruction. In 26 vessels, a high-grade lesion was incorrectly judged to be present on MDCT. The mean (± SD) diameter reduction of these false-positive lesions was 31% (± 22%). In seven vessels, a stenosis of intermediate degree (diameter reduction of between 50% and 70%) was present. If only assessable coronary arteries were considered, MDCT had a sensitivity of 91%, specificity of 89%, positive predictive value of 66%, and negative predictive value of 98% for detection of high-grade stenoses and occlusions.
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We observed the strong influence that a patient's heart rate during
scanning had on image quality and accuracy for stenosis identification on
MDCT. Even though we selected the optimal reconstruction window for every
individual coronary artery, motion artifacts could not be prevented in imaging
of 84 (21%) of the 400 coronary arteries, and motion artifacts were
significantly more frequent in patients with heart rates of more than 70
beats/min than in patients with lower heart rates ( 70 beats/min).
Consequently, overall stenosis detection was more accurate in patients with
low heart rates. A higher heart rate leads to a shorter R
wave—to—R wave interval because of the shorter end diastolic
portion of the cardiac cycle. This portion of the cardiac cycle is crucial to
image acquisition at current temporal resolution of 250 msec.
In an earlier study, the best image quality was found in patients with heart rates of less than 74.5 beats/min [11]. The researchers used a 5-point scale to assess the image quality in each coronary segment. However, their study was limited to the analysis of image quality and did not investigate the detection of coronary artery stenoses.
Optimal positioning of the image reconstruction window seems to be crucial
to achieving optimal image quality. It is known that each of the coronary
arteries has a different motion pattern during the cardiac cycle
[19,
20,
22]. Our findings confirm the
results of a recently published study
[15]. Images of the right
coronary artery were most frequently of sufficient quality earlier in the
cardiac cycle than were those of the left anterior descending and left
circumflex arteries. In addition, a patient's heart rate during MDCT scanning
had a strong influence on which cardiac phase provided the clearest
visualization of the coronary arteries. Although in patients with lower heart
rates ( 70 beats/min) the optimal window position was usually found during
mid to late diastole, the best image quality in patients with a heart rate of
more than 70 beats/min was found during late systole and early diastole. The
large variation in the optimal position of the image reconstruction window and
the differences between the coronary arteries suggest that careful positioning
and selection of the image reconstruction window are crucial factors to
obtaining optimal image quality and diagnostic accuracy on MDCT.
In contrast to coronary angiography performed with electron-beam CT, MDCT does not require a longer scanning duration for patients with lower heart rates. Therefore, a useful approach might be to limit the use of MDCT for coronary artery visualization to patients with lower heart rates or to use pharmacologic interventions (e.g., ß-blockers) during the scanning to enhance image quality and accuracy in the identification of coronary stenoses. In addition, technical developments, such as a decreased gantry rotation time and the simultaneous acquisition of more than four parallel slices may further improve image quality and diagnostic accuracy.
We conclude that contrast-enhanced MDCT with retrospectively ECG-gated image reconstruction is a promising tool in detecting coronary artery stenoses. However, many coronary arteries are currently nonassessable because of motion artifacts, and the accuracy of stenosis detection decreases as a patient's heart rate increases.
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U. J. Schoepf, C. R. Becker, B. M. Ohnesorge, and E. K. Yucel CT of Coronary Artery Disease Radiology, July 1, 2004; 232(1): 18 - 37. [Abstract] [Full Text] [PDF]
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U. Hoffmann, R. Millea, C. Enzweiler, M. Ferencik, S. Gulick, J. Titus, S. Achenbach, D. Kwait, D. Sosnovik, and T. J. Brady Acute Myocardial Infarction: Contrast-enhanced Multi-Detector Row CT in a Porcine Model Radiology, June 1, 2004; 231(3): 697 - 701. [Abstract] [Full Text] [PDF]
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H. S. Choi, B. W. Choi, K. O. Choe, D. Choi, K.-J. Yoo, M.-I. Kim, and J. Kim Pitfalls, Artifacts, and Remedies in Multi- Detector Row CT Coronary Angiography RadioGraphics, May 1, 2004; 24(3): 787 - 800. [Abstract] [Full Text] [PDF]
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A. Kuettner, A. F. Kopp, S. Schroeder, T. Rieger, J. Brunn, C. Meisner, M. Heuschmid, T. Trabold, C. Burgstahler, J. Martensen, et al. Diagnostic accuracy of multidetector computed tomography coronary angiography in patients with angiographically proven coronary artery disease J. Am. Coll. Cardiol., March 3, 2004; 43(5): 831 - 839. [Abstract] [Full Text] [PDF]
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M. J. Budoff, S. Achenbach, and A. Duerinckx Clinical utility of computed tomography and magnetic resonance techniques for noninvasive coronary angiography J. Am. Coll. Cardiol., December 3, 2003; 42(11): 1867 - 1878. [Abstract] [Full Text] [PDF]
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J. Gurevitch, T. Gaspar, B. Orlov, R. Amar, D. Dvir, N. Peled, and D. J. Aravot Noninvasive evaluation of arterial grafts with newly released multidetector computed tomography Ann. Thorac. Surg., November 1, 2003; 76(5): 1523 - 1527. [Abstract] [Full Text] [PDF]
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M. Naghavi, P. Libby, E. Falk, S. W. Casscells, S. Litovsky, J. Rumberger, J. J. Badimon, C. Stefanadis, P. Moreno, G. Pasterkamp, et al. From Vulnerable Plaque to Vulnerable Patient: A Call for New Definitions and Risk Assessment Strategies: Part I Circulation, October 7, 2003; 108(14): 1664 - 1672. [Abstract] [Full Text] [PDF]
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L. R. Van Hoe, K. G. De Meerleer, P. Ph. Leyman, and P. K. Vanhoenacker Coronary Artery Calcium Scoring Using ECG-Gated Multidetector CT: Effect of Individually Optimized Image-Reconstruction Windows on Image Quality and Measurement Reproducibility Am. J. Roentgenol., October 1, 2003; 181(4): 1093 - 1100. [Abstract] [Full Text] [PDF]
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H. K. Pannu, T. G. Flohr, F. M. Corl, and E. K. Fishman Current Concepts in Multi-Detector Row CT Evaluation of the Coronary Arteries: Principles, Techniques, and Anatomy RadioGraphics, October 1, 2003; 23(90001): S111 - 125. [Abstract] [Full Text] [PDF]
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K.-J. Yoo, D. Choi, B. W. Choi, S.-H. Lim, and B.-C. Chang The comparison of the graft patency after coronary artery bypass grafting using coronary angiography and multi-slice computed tomography Eur. J. Cardiothorac. Surg., July 1, 2003; 24(1): 86 - 91. [Abstract] [Full Text] [PDF]
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C R Peebles Non-invasive coronary imaging: computed tomography or magnetic resonance imaging? Heart, June 1, 2003; 89(6): 591 - 594. [Full Text] [PDF]
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D. Ropers, U. Baum, K. Pohle, K. Anders, S. Ulzheimer, B. Ohnesorge, C. Schlundt, W. Bautz, W. G. Daniel, and S. Achenbach Detection of Coronary Artery Stenoses With Thin-Slice Multi-Detector Row Spiral Computed Tomography and Multiplanar Reconstruction Circulation, February 11, 2003; 107(5): 664 - 666. [Abstract] [Full Text] [PDF]
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