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Noninvasive Evaluation of Cardiac Veins with 16-MDCT Angiography

¹ Department of Radiology, Massachusetts General Hospital and Harvard Medical School, CIMIT, 100 Charles River Plaza, Ste. 400, Boston, MA 02114.
² Department of Cardiology, Massachusetts General Hospital, Boston, MA 02114.
³ Present address: Department of Internal Medicine II (Cardiology), University of Erlangen-Nuremberg, Erlangen 91054, Germany.

Received August 31, 2004; accepted after revision November 10, 2004.

 
K. Nieman was supported by the Interuniversity Cardiology Institute of The Netherlands.

Address correspondence to S. Abbara.

Abstract

Top Abstract Introduction Materials and Methods Results Discussion References

 
OBJECTIVE. Anatomic mapping of the cardiac veins is important to guide transvenous therapeutic procedures such as biventricular pacing. As an alternative to invasive venography, we studied the feasibility of MDCT of the cardiac venous anatomy.

CONCLUSION. Cardiac venous anatomy is variable. MDCT is a noninvasive method that allows detailed imaging of the cardiac venous anatomy, including small cardiac veins and thebesian valves. Therefore, cardiac MDCT may be a valuable tool for guiding procedures that involve the cardiac venous system.

Introduction

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An increasing number of diagnostic and therapeutic procedures related to heart failure and arrhythmias make use of the venous system of the heart [1-7]. These include pacing-lead placement in the marginal vein or great cardiac vein for biventricular pacing devices and treatment of arrhythmia with transcoronary venous catheter radiofrequency ablation. Considering the interindividual anatomic variations, a need exists for accurate and detailed imaging of the cardiac veins for procedure guidance. Catheter-based direct or indirect venography does not always provide sufficient information and requires an invasive procedure that may cause discomfort and yield a small risk of serious complications [8].

Using ECG-gated MDCT with nonselective IV administration of contrast material, it is possible to acquire detailed and nearly motion-free images of the coronary arteries. The diagnostic accuracy of this technique for the detection of obstructive atherosclerotic coronary artery disease is promising. The feasibility of evaluating detailed venous anatomy in the same examination has been evaluated with electron beam CT [9]. Because of the relatively long total acquisition time, considerable opacification of the cardiac veins occurs even with scanning protocols tailored for coronary artery imaging. In this study, we evaluate the feasibility of noninvasive cardiac vein imaging using contrast-enhanced MDCT.

Materials and Methods

Top Abstract Introduction Materials and Methods Results Discussion References

 
Data Acquisition and Reconstruction
Retrospectively ECG-gated MDCT (Sensation 16, Siemens Medical Solutions) was performed in 54 consecutive patients (age, 58 ± 7.7 [SD] years; 33 men, 21 women). All patients were referred for suspected coronary artery disease; however, none had diagnostic cardiac enzyme elevation or ECG findings diagnostic of acute myocardial infarct. The purpose of CT angiography (CTA) was imaging of the coronary artery system to identify obstructive coronary artery disease. A ß-blocker (3-15 mg of metoprolol) was administered IV in patients with heart rates equal to or greater than 65 beats per minute (bpm), resulting in heart rates ranging from 49 to 72 bpm (mean, 61 ± 5.5 bpm) during the CTA acquisition. All patients were in sinus rhythm during the acquisition.

Image Acquisition Parameters
The scanner used in this study was equipped with 16 parallel detector rows with an individual detector width of 0.75 mm. The gantry rotation time was 420 msec. The scanning protocol was performed with a tube voltage of 120 kV and current of 550 mAs. To obtain optimal contrast enhancement in the coronary arteries, a test bolus of 20 mL of iodixanol (320 mmol I/mL) at 4 mL/sec was used to determine the contrast transit time. The contrast bolus during CTA, 68-92 mL depending on the scanning duration, was injected at 4 mL/sec. The scanning duration ranged from 17 to 23 sec (mean, 19.4 ± 1.4 sec). The patient was instructed to maintain an inspiratory breath-hold ( 20 sec) during data acquisition.

Using retrospective ECG gating, isophasic 1.0-mm axial slices were reconstructed at an increment of 0.5 mm. Because the partial-scan reconstruction algorithm requires CT data acquired during a 180° rotation for a single image, the average temporal resolution was 210 msec. This 210-msec reconstruction window could be placed at any position in the cardiac cycle, but the fewest motion artifacts were encountered during the diastolic cardiac phase: either a relative 55-65% of the R-to-R interval, or at an absolute time interval of 400-600 msec before the following R-wave. The data set at the time position least affected by cardiac motion was transferred to an offline 3D workstation (Leonardo, Siemens) for further analysis.

View larger version (10K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1 —Box-and-whisker plot shows median, upper median, lower median, smallest, and largest conspicuity values (0, vein not visible, to 10, excellent visualization) for analyzed cardiac venous segments. CS = coronary sinus, MCV = middle cardiac vein, PV = posterior vein of left ventricle, LV = lateral (marginal) vein, GCV = great cardiac vein, AIV = anterior interventricular vein.

To determine the contrast-to-noise ratio (CNR), small regions of interest (3-4 mm²) were placed centrally in the vein lumen and in immediately adjacent tissues in multiplanar reformations along the vein long axis. The mean CT attenuation at the respective locations was recorded for each evaluated vein segment. The image noise was determined by measuring the SD of the CT attenuation in the contrast-enhanced aorta by placing a 200 mm² region of interest in the same axial slice [10]. The CNR could then be calculated as follows:

where CT attenuation _lumen is the mean CT attenuation of a region of interest (3-4 mm²) placed in the contrast-enhanced lumen of the cardiac vein, CT attenuation _{connective tissue} is the mean density in a region of interest (3-4 mm²) placed in the perivascular fat immediately adjacent to the vein, and image noise is the SD of CT attenuation in a region of interest (200 mm²) placed in the aorta. Measurements included mean, SD, minimum, and maximum values.

Results

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Examination
MDCT coronary angiography was performed without complications in all patients. The entire coronary venous system could be visualized in all patients.

Image Quality
The conspicuity values ranged from 5.2 ± 2.3 at the lateral veins to 9.4 ± 0.9 at the coronary sinus (Fig. 1, Table 1). The CNR ranged from 6.0 ± 2.5 at the level of the anterior interventricular vein to 8.5 ± 3.6 at the middle cardiac vein level (Fig. 2). Positive correlation was found between the conspicuity values and the CNRs (p < 0.0001; nonparametric two-tailed Spearman's r = 0.48 [95% confidence interval = 0.34-0.61]) (Fig. 3).

View larger version (11K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2 —Box-and-whisker plot shows median, upper median, lower median, smallest, and largest contrast-to-noise ratio values for analyzed cardiac venous segments. CS = coronary sinus, MCV = middle cardiac vein, PV = posterior vein of left ventricle, LV = lateral (marginal) vein, GCV great cardiac vein, AIV = anterior interventricular vein.

View larger version (11K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3 —Scatterplot illustrates relation between conspicuity (0, vein not visible, to 10, excellent visualization) and contrast-to-noise ratio in 134 cardiac vein segments. Significant positive correlation is seen between conspicuity and measured contrast-to-noise ratio (p < 0.0001; nonparametric two-tailed Spearman's r = 0.48 [95% confidence interval = 0.34-0.61]).

Coronary Sinus
In all patients, the ostium of the coronary sinus could be located in the right atrium (Figs. 4A, 4B, 4C, 4D, 4E, and 4F). Thebesian valves, found at the inflow site of the coronary sinus into the right atrium, could be discerned in 18 patients (33%) (Figs. 5A, 5B, and 5C). The coronary sinus entered the right atrium below, at, and above the eustachian valve level in two (3.7%), 39 (72.2%), and 13 (24.1%) patients, respectively. The proximal coronary sinus diameter was 13.9 ± 3.2 mm.

View larger version (96K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —81-year-old woman with atypical chest pain. Three-dimensional volume-rendered reformations (A and B) and multiplanar maximum intensity projections along marginal left ventricular vein (C), in left ventricular long axis (D), in mitral-tricuspid valve plane (E), and along anterior interventricular vein (F) show large marginal vein (black arrows, A and C) and absence of posterior vein of left ventricle. Coronary sinus (open arrows, A, C, D, E), middle cardiac vein (arrowheads, A, C, D), and great cardiac vein (curved arrows, A and B) are well opacified. Anterior interventricular vein (straight white arrows, B and F) has lower contrast concentration because it is imaged several heartbeats earlier.

View larger version (90K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —81-year-old woman with atypical chest pain. Three-dimensional volume-rendered reformations (A and B) and multiplanar maximum intensity projections along marginal left ventricular vein (C), in left ventricular long axis (D), in mitral-tricuspid valve plane (E), and along anterior interventricular vein (F) show large marginal vein (black arrows, A and C) and absence of posterior vein of left ventricle. Coronary sinus (open arrows, A, C, D, E), middle cardiac vein (arrowheads, A, C, D), and great cardiac vein (curved arrows, A and B) are well opacified. Anterior interventricular vein (straight white arrows, B and F) has lower contrast concentration because it is imaged several heartbeats earlier.

View larger version (134K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C —81-year-old woman with atypical chest pain. Three-dimensional volume-rendered reformations (A and B) and multiplanar maximum intensity projections along marginal left ventricular vein (C), in left ventricular long axis (D), in mitral-tricuspid valve plane (E), and along anterior interventricular vein (F) show large marginal vein (black arrows, A and C) and absence of posterior vein of left ventricle. Coronary sinus (open arrows, A, C, D, E), middle cardiac vein (arrowheads, A, C, D), and great cardiac vein (curved arrows, A and B) are well opacified. Anterior interventricular vein (straight white arrows, B and F) has lower contrast concentration because it is imaged several heartbeats earlier.

View larger version (107K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4D —81-year-old woman with atypical chest pain. Three-dimensional volume-rendered reformations (A and B) and multiplanar maximum intensity projections along marginal left ventricular vein (C), in left ventricular long axis (D), in mitral-tricuspid valve plane (E), and along anterior interventricular vein (F) show large marginal vein (black arrows, A and C) and absence of posterior vein of left ventricle. Coronary sinus (open arrows, A, C, D, E), middle cardiac vein (arrowheads, A, C, D), and great cardiac vein (curved arrows, A and B) are well opacified. Anterior interventricular vein (straight white arrows, B and F) has lower contrast concentration because it is imaged several heartbeats earlier.

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4E —81-year-old woman with atypical chest pain. Three-dimensional volume-rendered reformations (A and B) and multiplanar maximum intensity projections along marginal left ventricular vein (C), in left ventricular long axis (D), in mitral-tricuspid valve plane (E), and along anterior interventricular vein (F) show large marginal vein (black arrows, A and C) and absence of posterior vein of left ventricle. Coronary sinus (open arrows, A, C, D, E), middle cardiac vein (arrowheads, A, C, D), and great cardiac vein (curved arrows, A and B) are well opacified. Anterior interventricular vein (straight white arrows, B and F) has lower contrast concentration because it is imaged several heartbeats earlier.

View larger version (100K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4F —81-year-old woman with atypical chest pain. Three-dimensional volume-rendered reformations (A and B) and multiplanar maximum intensity projections along marginal left ventricular vein (C), in left ventricular long axis (D), in mitral-tricuspid valve plane (E), and along anterior interventricular vein (F) show large marginal vein (black arrows, A and C) and absence of posterior vein of left ventricle. Coronary sinus (open arrows, A, C, D, E), middle cardiac vein (arrowheads, A, C, D), and great cardiac vein (curved arrows, A and B) are well opacified. Anterior interventricular vein (straight white arrows, B and F) has lower contrast concentration because it is imaged several heartbeats earlier.

View larger version (144K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —Three patients with atypical chest pain. Cardiac-gated MDCT scans with multiplanar maximum intensity projections show thebesian valve at coronary sinus ostium (arrow) in 52-year-old man (A) and anterior cardiac vein draining directly into right atrium after crossing right coronary artery in atrioventricular groove (arrows) in 49-year-old man (B).

View larger version (147K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —Three patients with atypical chest pain. Cardiac-gated MDCT scans with multiplanar maximum intensity projections show thebesian valve at coronary sinus ostium (arrow) in 52-year-old man (A) and anterior cardiac vein draining directly into right atrium after crossing right coronary artery in atrioventricular groove (arrows) in 49-year-old man (B).

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5C —Three patients with atypical chest pain. Volume-rendered image of inferior cardiac surface shows small cardiac vein (solid arrows) draining into middle cardiac vein (arrowhead) in 63-year-old woman. Note coronary sinus (open arrow).

View larger version (139K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6 —58-year-old man with atypical chest pain. Multiple projections of vessel centerline reconstruction show uninterrupted visibility of vein on cardiac surface over distance of 17.6 cm. Note coronary sinus (open arrow), great cardiac vein (solid arrows), anterior interventricular vein (curved arrow), ostia (arrowheads) of middle cardiac vein (MCV), posterior left ventricular vein (PV), and marginal (lateral) vein (MV). LAA = left atrial appendage, LA = left atrium, LV = left ventricle.

Lateral and Posterior Veins
In four patients (7.4%), no left lateral veins could be identified; and in 11 patients (20.4%), no posterior vein could be found. In all patients, either a posterior vein or a lateral vein was present. In 11 patients (20.4%) there was one, in 29 (53.7%) there were two, and in 14 (25.9%) there were three or more branches along the posterolateral left ventricular wall. The lateral vein was more dominant in appearance than the posterior vein in 30 patients (55.6%). The ostia of the posterior and left lateral branches were found at a distance from the coronary sinus ostium ranging from 13 to 49 mm (23.4 ± 8.9 mm) and from 27 to 81 mm (mean, 59.7 ± 18.2 mm), respectively. The visualized length of the largest lateral vein measured 60-152 mm (mean, 105.8 ± 26.6 mm), and the diameter near the take-off from the great cardiac vein was 2-4 mm (mean, 2.7 ± 0.8 mm).

Small Cardiac Veins
Small cardiac veins, which run parallel to the distal right coronary artery in the atrioventricular groove, draining in either the middle cardiac vein or the coronary sinus, were visible in five patients (9.3%). Small anterior cardiac veins, draining the right ventricular anterior free wall and entering the right atrium directly, were seen in 23 patients (42.6%) (Figs. 5A, 5B, and 5C).

Discussion

Top Abstract Introduction Materials and Methods Results Discussion References

 
In the past decade, the cardiac venous system has been increasingly used for therapeutic cardiac procedures. Ventricular resynchronization therapy [4] requires placement of leads in the coronary veins. Radiofrequency ablation and myoblast transplantation can be performed via the venous system of the heart. To plan and perform transvenous interventions, knowledge of the individual coronary venous system is essential [4, 6]. Venous anatomy is variable [11-13]. Although individual sizes vary, the middle and great cardiac veins, which extend into the anterior interventricular vein, can be found in nearly all patients. Localization and size of the lateral and posterior venous branches are more variable, and in 1-3% of patients no vein of substantial size can be found along the posterolateral ventricular wall [11, 13].

The imaging appearance of the coronary sinus on single-slice nongated mechanical CT was described as early as 1985 [14]. However, the absence of ECG gating, poor temporal resolution, and large slice thickness did not allow visualization of the more peripheral coronary venous system.

MDCT Cardiac Venography
In this study we have shown the feasibility of venous imaging using MDCT. Although CT angiography was performed for imaging of the coronary arteries and venous opacification was suboptimal, the anatomy of the veins draining into the coronary sinus could be evaluated in all patients. Large and small branches could be visualized over a considerable distance without interruption. Vessel diameter could be measured to determine whether a vein could be accessed by a lead or other therapeutic device. Centerline reconstructions have proven valuable in CTA of other vessels, such as in aortic aneurysms, before endovascular therapy planning [15]. In our study, these reconstructions were helpful in determining the vessel length and diameter. In addition, MDCT allowed noninvasive visualization of the thebesian valves and small cardiac veins. Simultaneous imaging of the venous anatomy and other cardiac structures, such as the coronary arteries and the myocardium, may be useful to plan therapeutic procedures such as injection of myoblasts, ablation procedures, and novel transvenous coronary revascularization.

Because venous enhancement increases as the data acquisition proceeds, conspicuity and CNR improved in a craniocaudal direction— that is, from the anterior interventricular vein to the coronary sinus. This study has confirmed a positive correlation of CNR to subjective conspicuity, a measure of image quality.

Cardiac Veins on Electron Beam CT
Cardiac vein imaging with electron beam CT is feasible, but in some studies insufficient coverage of the heart and suboptimal image quality prevented complete evaluation in a substantial number of patients [9, 16]. Visualization of the small cardiac veins or thebesian valves on electron beam CT has not been reported. Reasons for the better performance of MDCT include the higher spatial resolution and better signal to noise ratio; retrospective ECG gating that allows reconstruction of the most motion-sparse period of the cardiac cycle and is less sensitive to irregular or misinterpreted ECGs; and the shorter scanning time of current MDCT technology compared with the electron beam CT scanners used in these studies.

Invasive Cardiac Venography
Retrograde venography is a catheter-based technique that requires cannulation and balloon occlusion of the coronary sinus, injection of a contrast medium in one or more directions, and cineangiography in at least two directions. In most patients, the cardiac vein anatomy can be visualized and venous accessibility determined. Reported disadvantages of this method are the complicated localization of the coronary sinus ostium, incomplete direct vein visualization, balloon-related trauma to the coronary sinus, excessive use of contrast material (up to 500 mL in one study), and the inability to visualize the venous anatomy in relation to the ventricular wall [6]. Meisel et al. [8] performed retrograde venography in 129 patients. In that study, coronary sinus cannulation failed in 4%, complete occlusion could not be achieved in 15%, and poor image quality and technical complications occurred in 14% of patients. The mean examination time was 25 min but ranged up to 105 min. The average amount of contrast medium used was 169 mL (range, 40-500 mL). An intraventricular vein and middle cardiac vein could be identified in all but one patient. One, two, or more substantial lateral or posterior veins could be discerned in 51%, 46%, and 2%, respectively, and only one patient had neither vein. In contrast, MDCT is a non-invasive technique with no risk of damage to the coronary sinus. The amount of contrast material used in MDCT venography rarely exceeds 100 mL. Furthermore, MDCT venography does not require potentially damaging cannulation or balloon occlusion of the coronary sinus.

Limitations and Future Development
Timing of the contrast material injection was optimized for the imaging of coronary arteries in our study. A contrast injection protocol dedicated to coronary vein imaging should substantially improve the performance of MDCT. The timing of the contrast bolus may become more important when using the recently introduced 64-MDCT technology, which has an even shorter scanning time. This shorter scanning time will necessitate temporally tighter contrast enhancement protocols, and venous opacification may be insufficient using scanning protocols tailored for imaging the coronary artery system. A longer time between contrast injection and initiation of scanning may be required to visualize the cardiac veins. When imaging of both the coronary arteries and veins is required, the contrast-enhancement plateau needs to be extended. A dedicated venous contrast-enhancement protocol combined with higher spatial resolution can be expected to further improve the qualitative and quantitative assessment of the coronary veins.

Conclusion
We have shown the feasibility of CT coronary venous imaging, which may prove useful in the planning of transvenous procedures such as biventricular pacing and ablation therapy. Further research is needed to determine the clinical benefit of this noninvasive imaging method over standard techniques.

References

Top Abstract Introduction Materials and Methods Results Discussion References

 

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This Article Abstract Figures Only Full Text (PDF) 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 Abbara, S. Articles by Achenbach, S. Search for Related Content PubMed PubMed Citation Articles by Abbara, S. Articles by Achenbach, S. Social Bookmarking                      What's this? Hotlight (NEW!) What's Hotlight?