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ABSTRACT |
Monday, May 7, 10:00 AM–12:00 PM
Abstracts 011-022
Moderator(s): Smita Patel and Jill Jacobs
10:00 AM
011. Multidetector CT Angiography for Assessment of Coronary Artery Disease: A Systematic Review of Diagnostic Performance
Vanhoenacker P. K.3*; Heijenbrok-Kal M. H.2; Vanheste R.3; Decramer I.3; Van Hoe L. R.3; Wijns W.1; Hunink M. M.2 1. Cardiovascular Center Aalst, Aalst, Belgium; 2. Erasmus MC-University Medical Center, Rotterdam, The Netherlands; 3. OLV Ziekenhuis, Aalst, Belgium
Address correspondence to P. Vanhoenacker (piet{at}vanhoenacker.be)
Objective: To review the literature on the diagnostic performance of multidetector computed tomography angiography (MDCTA), with conventional coronary angiography (CA) as reference standard for assessment of symptomatic coronary artery disease.
Materials and Methods: A Pubmed and manual search of the literature published between January 1998 and May 2006 on MDCTA compared with CA in patients with symptomatic coronary artery disease was performed. Summary estimates of diagnostic odds ratio, sensitivity and specificity were calculated. Random-effects models were used to compare the diagnostic performance of 4-, 16-, and 64-detector-MDCTA and the proportion of nonassessable segments was evaluated.
Results: Fifty-four studies were included in the meta-analysis: 22 studies on 4-detector MDCTA, 26 on 16-detector MDCTA and 6 on 64-detector MDCTA. The pooled sensitivity and specificity for detecting a >50% stenosis per segment were 0.93 (95%CI, 0.88–0.97) and 0.96 (95%CI, 0.96–0.97) for 64-detector MDCTA, 0.83 (95%CI, 0.76–0.90) and 0.96 (95%CI, 0.95–0.97) for 16-detector MDCTA, and 0.84 (95%CI, 0.81–0.88) and 0.93 (95%CI, 0.91–0.95) for 4-detector MDCTA, respectively. Regression analysis showed that the diagnostic performance significantly improved with the new generations of MDCT scanners (64- and 16-detector versus 4-detector CT), adjusted for exclusion of nonassessable segments, and contrast concentration used. Simultaneously, the nonassessable proportion of coronary segments significantly decreased with the new generations of MDCT scanners, adjusted for heart rate, prevalence of significant disease and mean age.
Conclusion: With the new generations of MDCT scanners the diagnostic performance for the assessment of coronary artery disease has significantly improved, while the nonassessable proportion of segments decreased.
012. The Role of Coronary Angiography in the Differential Diagnosis of Different Cardiac and Extra Cardiac Diseases
Amashukeli M.; Onashvili N.* TSMU, Tbilisi, Georgia
Address correspondence to N. Onashvili (nikaonashvili{at}caucasus.net)
Objective: The coronary angiography is one of the most informational methods of investigation. In one part of patients the nonstenotic coronary arteries are revealed. Our objective is to find out the frequency of nonstenotic coronaries, the possible underlying cardiac and extracardiac causes of angina-like chest pain in case of nonstenotic coronaries and the role of coronary angiography in the differential diagnosis of these disorders.
Materials and Methods: We studied the histories and the results of investigations of 80 patients for this purpose. The investigation was conducted with coronary angiography.
Results: It turned out that 17 of them (21%) had nonstenotic coronary arteries. That's the group of patients, where we need to differentiate among many diseases and conditions, which can cause angina-like pain in the chest. In 5 cases this investigation enabled to make exact diagnoses, but in 12 cases it was impossible to differentiate among Syndrome-X and other gastrointestinal or psychological disorders, especially because they often coexist.
Conclusion: So we can conclude that not all cases of pain in the chest are associated with coronary artery disorders and even coronary angiography is unable to make final diagnoses in some cases.
013. Contrast Bolus Optimization for Cardiac 16-slice Computed Tomography: Comparison of Contrast Medium Formulations Containing 300 and 400 mg Iodine/ml
Rist C.3*; Nikolaou K.3; Kirchin M. A.5; von Ziegler F.2; Roland V.1; T y Bae K.4; Knez A.2; Wintersperger B. J.3; Reiser M. F.3; Becker C. R.3 1. Bracco Altana Pharma GmbH, Konstanz, Germany; 2. Department of Cardiology–Grosshadern, University of Munich, Munich, Germany; 3. Department of Clinical Radiology–Grosshadern, University of Munich, Munich, Germany; 4. Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO; 5. Worldwide Medical Affairs, Bracco Imaging SpA, Milan, Italy
Address correspondence to C. Rist (carsten.rist{at}med.uni-muenchen.de)
Objective: The aims of our study were to compare contrast injection protocols with contrast media containing 300 and 400 mg iodine/ml for optimal contrast enhancement in cardiac MDCT, and to evaluate the correlation of test bolus curve parameters with the final contrast density of the main bolus.
Materials and Methods: Sixty patients with known or suspected coronary artery disease were included in a prospective double-blind study. Patients were randomized to two groups. Group 1 received 83 ml of a contrast medium (CM) containing 300 mg of iodine (Iomeron 300®, Bracco Imaging SpA, Milan, Italy) at a flow rate of 3.3 ml/sec, while group 2 received 63 ml of the same agent containing 400 mg of iodine (Iomeron 400®) at a flow rate of 2.5 ml/sec. The test bolus volumes were 20 ml and 15 ml, respectively. Imaging was performed using a 16-slice CT system (16DCT; Somatom Sensation 16, Siemens Medical Solutions, Forchheim, Germany). Contrast densities (Hounsfield Units, HU) were determined in the cardiac chambers and in the main coronary arteries. The peak density and area under the curve (AUC) of the test bolus were calculated for each patient.
Results: The mean contrast densities of the coronary arteries were 259.1 ± 46.7 HU for group 1 and 251.6 ± 51.0 HU, for group 2. No noteworthy differences between groups were noted for density measurements in the cardiac chambers or for the ratio of right-to-left ventricle density. Whereas a positive correlation was noted for both groups between the AUC of the test bolus and the mean density of the main bolus, a positive correlation between peak density of the test bolus and mean density of the main bolus was noted only for group 1.
Conclusion: Equivalent homogeneous enhancement of the ventricular cavities and coronary arteries to that obtained using a CM with standard iodine concentration (Iomeron 300®) can be achieved with lower overall volumes of administered CM and reduced injection flow rates when a CM with high iodine concentration (Iomeron 400®) is used.
014. High-intracoronary Attenuation Improves Diagnostic Accuracy of 64-slice Computed Tomography Angiography in the Detection of Coronary Stenoses
Palumbo A.1*; Maffei E.1; Pugliese F.2; La Fata L.1; Damiani L.1; Mollet N. R.2; Cademartiri F.1 1. Azienda Ospedaliero-Universitaria, Parma, Italy; 2. Erasmus Medical Center, Rotterdam, The Netherlands
Address correspondence to A. Palumbo (filippocademartiri{at}hotmail.com)
Objective: Assess the effect of intra-coronary attenuation on diagnostic accuracy using 64-slice computed tomography coronary angiography (CT-CA).
Materials and Methods: 170 patients with suspected coronary artery disease who underwent conventional CA and CT-CA were enrolled for the study. Patients underwent CT-CA with the following protocol: collimation 32 x 2 x 0.6 mm, rotation time 330 ms, 100 ml of Iomeprol 400/ml at 4 ml/s. The average vascular attenuation measured in the aortic root and in coronary arteries, was used to divide the population in two groups of 85 patients each, one with lower attenuations (low), and one with higher attenuations (high). Diagnostic accuracy for the detection of significant coronary artery stenosis with CA as reference standard was compared between the two groups with a McNemar's test and a p < 0.05 was considered significant.
Results: Overall 1858 (940 for low and 918 for high) segments with 290 (148 for low and 142 for high) significant lesions were available for the analysis. No significant difference was found between age, gender, image noise, heart rate, coronary calcium score and body mass index between the two groups. The average intra-coronary attenuation was 297 ± 29 HU and 388 ± 46 HU for low and high, respectively (p < 0.05). The sensitivity and specificity were 91% and 93% for Low and 96% and 97% for High.
Conclusion: High intracoronary attenuation significantly improves diagnostic accuracy in 64-slice CT-CA. Therefore, intravenous contrast material protocols for CT-CA should aim at the maximum intravascular attenuation.
015. Evaluation of the Optimal Image Reconstruction Interval for Coronary Artery Imaging Using 64-slice CT
Weininger M.*; Ritter C.; Beer M.; Hahn D.; Beissert M. University of Wuerzburg, Wuerzburg, Germany
Address correspondence to M. Weininger (weininger{at}roentgen.uniwuerzburg.de)
Objective: To prospectively evaluate if there is a specific image reconstruction interval providing optimal image quality for all coronary segments and each coronary artery.
Materials and Methods: 296 coronary artery segments of 20 patients (14 men, 6 women; mean age 54 ± 10 years) with a mean heart rate of 66 ± 12 beats per minute (bpm) were analyzed using a 64-slice CT scanner and a standardized scanning protocol. Oral ß-blockers were administered to 10 patients with a baseline heart rate >70 bpm. Data reconstruction was performed in 5% increments (5%–100% of the R-R interval) using maximum intensity projections (slice thickness, 3.0 mm; reconstruction increment, 1.5 mm). Four experienced observers independently evaluated image quality of the coronary arteries according to the 15 segment AHA classification. A 3-point ranking scale was applied: 1, very poor, no evaluation possible; 2, diagnostically sufficient quality; 3, highest image quality.
Results: In the mean of all patients the best reconstruction point for all 15 segments was found to be at 65% of the R-R interval (mean 2.3 ± 0.5; p < 0.05). Divided into each coronary artery best image quality could be achieved by again referencing image reconstruction to 65% of R-R: RCA, 2.1 ± 0.5; LCA, 2.3 ± 0.5; LM, 2.5 ± 0.2; LAD, 2.3 ± 0.4; LCX, 2.3 ± 0.5. No significant influence of the heart rate was found.
Conclusion: By using a 64-slice CT scanner with a gantry rotation time of 330 milliseconds the need for accordingly adjusting the reconstruction point to each coronary segment might be overcome as diagnostically sufficient image quality as well as best image quality could be achieved with image reconstruction at 65% of the R-R interval for all coronary segments.
016. Comparison Study of Coronary CTA with Conventional Invasive Coronary Angiogram
Zhang S.*; Halpern E.; Levin D. Thomas Jefferson University, Philadelphia, PA
Address correspondence to S. Zhang (shaoxiong.zhang{at}jefferson.edu)
Objective: To investigate the usefulness of coronary CTA for detection of coronary disease in comparison to invasive coronary angiogram.
Materials and Methods: 57 patients, aged 55 ± 9 years, underwent both ECG-gated Coronary CTA using a Brilliance Pro MDCT scanner (Philips Medical Systems) and invasive coronary angiogram. Coronary CTA and catheter-based coronary angiogram were conducted within one-month interval in patients whose symptom remained the same. Coronary CTA images were read blindly to invasive coronary angiogram. Significant stenosis was defined as more than 50% reduction in coronary luminal diameter. Every coronary artery was divided into 15 standard segments for direct comparison of the images obtained from 2 modalities.
Results: Significant stenosis was identified in 30 subjects with invasive coronary angiogram. Among them, similar coronary stenosis was found in 27 patients with coronary CTA. 27 subjects had no significant stenosis on invasive coronary angiogram and 25 of them had negative results on coronary CTA. 855 coronary segments from 57 patients were evaluated. 96 segments were demonstrated significant coronary stenosis. Among them, 73 segments were shown similar stenosis on CTA. 23 segments were underestimated/overestimated due to small vessel or heavily calcification. No significant disease on invasive coronary angiogram was found in 759 segments. Among them, no significant lesion was observed in 737 segments on coronary CTA. In addition, coronary CTA provided detailed information on lesions resulting from calcified versus soft plaque. The sensitivity, specificity, positive predict value, negative predict value and accuracy of coronary CTA as compared to invasive coronary angiogram in detection of significant stenosis were 90%, 93%, 93%, 89% and 91%, respectively.
Conclusion: Coronary artery CTA using MDCT is an excellent noninvasive method in detecting significant coronary stenosis with high accuracy as compared to invasive coronary angiogram. Stenosis in small branches, distal segment as well as severe calcifications, were the main sources of underestimate or overestimate coronary atherosclerotic lesion on coronary CTA images.
017. Dual-source Computed Tomography Angiography for the Assessment of In-stent Restenosis in Coronary Arteries
Pugliese F.*; Alberghina F.; Weustink A. C.; Otsuka M.; Mollet N. R.; de Feyter P. J.; Krestin G. P. Erasmus MC, Rotterdam, Netherlands
Address correspondence to F. Pugliese (francesca.pugliese{at}libero.it)
Objective: To evaluate the efficacy of dual-source computed tomography coronary angiography (DSCT-CA) for the detection of in-stent restenosis (=50% stenosis) in a prospective cohort of patients referred for repeat conventional angiography.
Materials and Methods: Forty-five patients (34 men) with previous percutaneous stent implantation underwent prospectively ECG-gated DSCT-CA (Somatom Definition, Siemens, Germany). Subjects in stable hemodynamic status and sinus heart rhythm were included. Exclusion criteria were renal insufficiency, irregular heart rhythm and contrast allergy. The patients did not receive premedication with beta-blockers. Two datasets were reconstructed with a 16–18 cm FOV using B26f and B46f kernels. A 3rd dataset with a 10–12 cm FOV was reconstructed.
Results: The average heart rate was 67 ± 13 beats per minute (range 47–107). Eighty-one stents were present (diameter range = 2.25–5mm). Nine stents were occluded and 15 had in-stent restenosis at quantitative coronary angiography (prevalence of disease 24/81 = 30%). The accuracy of DSCT-CA for the detection of stent occlusion resulted absolute (area under ROC curve = 0.99). For the assessment of in-stent restenosis, we found a sensitivity of 92%, specificity of 82%, PPV of 61%, and NPV of 98% when the B46f dataset was analyzed (area under ROC curve = 0.81). In the availability of the other datasets (B26f kernel and small FOV) the specificity increased to 96% and PPV to 78% (area under ROC curve = 0.85).
Conclusion: DSCT-CA reliably detects coronary stent occlusion at all heart rates. For the detection of in-stent restenosis, the analysis of multiple datasets reconstructed with a dedicated sharp convolution kernel, a smooth-medium kernel, and with a smaller FOV is advisable to improve efficacy.
018. Evaluating Left Ventricular Function: A Comparison of 64-Row Cardiac CT to 2D Echocardiography
Pereira A. M.*; Paul N.; Doyle D.; Pen V.; Provost Y. University Health Network/Mount Sinai Hospital, Toronto, Canada
Address correspondence to A. Pereira (andre.pereira{at}uhn.on.ca)
Objective: Evaluation of cardiac function is an important aspect of cardiac assessment with 64-row MDCT. Optimal patient preparation for CT coronary angiography (CTCA) includes the use of a beta blocker and sublingual nitrates. These medications alter cardiac hemodynamics and contractility and therefore potentially adversely affect assessment of cardiac function. The purpose of this study was to compare CTCA with 2D echocardiography (echo) in assessing left ventricular function.
Materials and Methods: A retrospective review of 100 patients referred for CTCA to exclude coronary artery disease (CAD) from Mar–Aug 2006. All patients had a cardiac CT performed on a 64-row MDCT (Aquillion, Toshiba, Japan) and 2D echocardiography. Both examinations were performed within an 8-week window, all patients remained clinically stable during this period. CT data was reconstructed into 10 equal phases, 0-90%, and analyzed on a standalone 3D workstation (Vitrea, Vital Images) by contouring the left ventricular cavity on consecutive slices in end diastole and end systole with subsequent generation of values for the end diastolic, end systolic volumes and the ejection fraction (EF). For 2D echocardiography, a bi-dimensional technique was used to calculate the ejection fraction using Simpson's rule. We stratified the EF in the following groups: A, normal (55 to 65%), B, mildly reduced (45 to 55%), C, moderately reduced (35 to 45%) and D, severely reduced (less than 35 %).
Results: In progress: 43 patients have been analyzed; 30 M: 13 F mean age 56.6 years (21–82). Grading of LV function as follows: CT: A = 15 patients (35%), B = 15 patients (35%), C = 9 patients (21%) and D = 4 patients (9%). Echo: A = 30 patients (70%), B = 7 patients (16%), C = 2 patients (5%) and D = 4 patients (9%). Concordant results were noted in 44.1% (19/43) of patients notably in patients with the most severely depressed ventricular function (Gp. D). In comparison with echo, CT tended to underestimate the EF; 70% of patients were stratified into groups A and B, compared to 86% of patients for echo.
Conclusion: Preliminary: Patient pre-medication with beta-adrenergic blocking agents and nitrates prior to cardiac CT cause an underestimation of systolic function in patients with normal or slightly reduced systolic function when compared to echocardiography. Concordance is improved in patients with severely reduced LV function.
019. Dual-Source CT in Congenital Heart Disease
Ruehm S.*; Lohan D.; Krishnam M.; Panknin C.; Lell M. M. UCLA, Los Angeles, CA
Address correspondence to S. Ruehm (sruehm{at}mednet.ucla.edu)
Objective: Dual source CT (DSCT) provides a temporal resolution of 83 ms, independent of the heart rate. This promises motion free depiction of the heart at higher heart rates. The aim of our study was to evaluate the potential of dual-source cardiac CTA in patients with congenital heart disease.
Materials and Methods: 20 patients were examined preoperatively or had a postoperative follow-up with DSCT. Scan parameters were 2 x 350 mAs, 120 kV, 60–80 ml contrast material was injected at a rate of 3–5 ml/s. Image reconstruction was performed with an adapted field of view and a medium convolution kernel (B31) with a slice thickness of 0.75 mm and a reconstruction increment of 0.5 mm. Multiphasic reconstruction (reconstruction in 5% increments of the RR-cycle) was performed additionally (slice thickness 1 mm, reconstruction increment 0.7 mm) for the assessment of cardiac function.
Results: All examinations could be performed successfully without lowering the heart rate using ß-blockers. Morphologic anomalies as well as results of surgical procedures could be well visualized, even in small children. Motion artifacts were minimal and did not interfere with diagnosis. Studying valve motion was feasible even inside valved conduits.
Conclusion: Our initial experiences hold promise that DSCT can improve the pre- and postoperative evaluation of patients with congenital heart disease. Administration of ß-blockers to reduce the heart rate does not seem to be necessary.
020. A Novel CT Technique for Fontan Circulations
Pen V.*; Provost Y.; Paul N. S.; Dos Subira L. University of Toronto, Toronto, Canada
Address correspondence to V. Pen (penv{at}hotmail.com)
Objective: To review the physiology in Fontan circulation. To describe the different types of Fontan procedures. To address common complications associated with the Fontan circulation. To describe an optimal CT technique used to comprehensively assess the Fontan circuit and pulmonary arteries
Materials and Methods: We reviewed all CT angiography examinations of patients with Fontan circulation performed from January 2002 to September 2006 at our institution, a tertiary referral center for adult congenital heart disease. In total, 25 studies were identified: 16 with upper limb venous access (group A) and 9 with concomitant upper and lower limb venous access (group B). In group A, 13 (81%) exams were performed to rule out pulmonary emboli, 1 (6.5%) to exclude Fontan compression and 2 (12.5%) for assessment of pulmonary veins pre-ablation. All group B studies were performed to exclude thrombus. We will describe the CT technique in these two groups. The examinations were qualitatively evaluated to assess: 1. Homogeneous opacification of the Fontan circuit and pulmonary arteries, 2. artifacts due to slow blood flow and contrast media, and 3. the radiologists' level of confidence in confirming or excluding the presence of thrombus. They were also quantitatively analyzed to compare the total volume of contrast media injected and number of CT phase acquisitions per examination. Two radiologists reviewed all the studies and the radiological reports contemporary to the time of study.
Results: Comparing the two study groups, group B had: Superior opacification of the Fontan circuit and pulmonary arteries, without artifacts from slow flowing blood or contrast media. (Streaming and/or layering artifacts were described in group A patients.) A higher level of diagnostic confidence in interpretation. A larger total volume of contrast media used. Two acquisition phases/examination as compared to group A in which there were at least two acquisitions and in one case up to 4 phases, constituting a larger radiation dose burden to the patient.
Conclusion: Our experience suggests that concomitant upper and lower limb intravenous contrast media injection combined with a 2-phase volumetric acquisition during MDCT angiography accommodates the altered hemodynamics of a Fontan circulation and can significantly reduce the possibility of a false-positive diagnosis of thrombus at a reduced radiation dose when compared to an upper limb injection.
021. Coronary Sinus Compression: An Early CT Sign of Cardiac Tamponade
Gold M. M.; Spindola-Franco H.; Jain V. R.*; Spevack D. M.; Haramati L. B. Montefi ore Medical Center, Bronx, NY
Address correspondence to V. Jain (vjain{at}montefiore.org)
Objective: To retrospectively determine the distinguishing features of cardiac tamponade on conventional chest computed tomography (CT).
Materials and Methods: Blinded retrospective analysis of CT scans from 14 patients (6 women, 8 men; age range 49–93 years; mean age, 71 years) with echocardiographic evidence of tamponade and 15 controls (11 women, 4 men; age range 37–96 years; mean age, 66 years) was performed by three cardiothoracic radiologists. CT scans were analyzed for right ventricular flattening, contrast reflux into the azygos vein, and coronary sinus compression. IVC and SVC short axis diameter and pericardial fluid density were recorded. If the pericardium or pericardial fluid were sampled, results were noted. Case and control group variables were compared using the Fisher exact test and the t test. Results were also subjected to logistic regression analysis.
Results: Coronary sinus compression was present in 46% (6 of 13) patients with tamponade and in no controls (p = 0.006). Trends toward IVC dilatation and elevation of pericardial fluid density in cases of tamponade did not reach statistical significance. A specific pathological diagnosis was made in 88% (7 of 8) of tamponade cases and 29% (2 of 7) of controls (p = 0.04).
Conclusion: The detection of coronary sinus compression on CT is an early specific indicator of cardiac tamponade. Dilatation of the IVC and the presence of elevated pericardial fluid density are CT signs suggestive of the diagnosis.
022. Left Atrial Diverticulum is a Normal Variant that May be Confused for Pseudoaneurysm on Gated Cardiac CT
Rutkowski A.*; Ozel B.; Broderick L.; Keevil J.; Reeder S. University of Wisconsin Hospital and Clinics, Madison, WI
Address correspondence to A. Rutkowski (arutkowski{at}uwhealth.org)
Objective: To determine the prevalence and characterize a left atrial anatomic variant that can have the appearance of a pseudoaneurysm on gated cardiac CT.
Materials and Methods: The study group consisted of 50 patients (mean age, 60.8 years; 31 men, 19 women) who underwent gated CT coronary angiography on a 64-slice multi-detector CT. Informed consent and IRB approval was obtained. The source images were reviewed by 3 experienced radiologists (BO, AR, SR) and the prevalence of a diverticulum along the right/anterior/superior aspect of the left atrium was tabulated by consensus. The maximum orifice diameter and maximum length of each diverticulum was measured. The shape of each diverticulum was classified into one of three categories: curvilinear projecting superiorly (Type 1), round outpouching (Type 2), or complex (multiple orifices communicating, multilobed) (Type 3).
Results: Of the 50 patients imaged, 36 had a diverticulum along the right/anterior/superior aspect of the left atrium (72% of patients). The average orifice diameter was 4.4 mm (range = 1–9 mm). The average maximum length was 4.9 mm (range = 1–11). There were 21/35 (60%) type 1 diverticula, 12/35 (34%) type 2 diverticula, and 3/35 (9%) type 3 diverticula.
Conclusion: The advent of gated cardiac CT has allowed unprecedented resolution of cardiac anatomy without cardiac motion artifact. A significant proportion of these patients have a normal anatomic variation along the right/anterior/superior aspect of their left atrium that has not been described in standard anatomy textbooks or radiology journals to date. This diverticulum may be mistaken for a pseudoaneurysm, particularly in patients who have been previously instrumented. This study demonstrates the importance of recognizing this normal left atrial variant and avoiding the pitfall of mistaking it for a left atrial pseudoaneurysm.
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