DOI:10.2214/AJR.07.3484
AJR 2008; 191:64-72
© American Roentgen Ray Society
Comprehensive Evaluation of Ischemic Heart Disease Using MDCT
I-Chen Tsai1,2,3,4,
Wen-Lieng Lee2,3,4,5,
Chen-Rong Tsao2,3,4,5,
Yen Chang5,
Min-Chi Chen1,
Tain Lee1,2,3,4 and
Wan-Chun Liao1
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.
Received December 2, 2007;
accepted after revision January 8, 2008.
Address correspondence to I. C. Tsai
(sillyduck.radiology{at}gmail.com).
CME
This article is available for CME credit. See
www.arrs.org
for more information.
Abstract
OBJECTIVE. Recently MDCT has become widely used for the evaluation
of ischemic heart disease, but clinically the evaluation is primarily focused
on the coronary artery only. We describe why and how to comprehensively
evaluate the cardiac CT scan, including myocardium, motion, viability, valve,
and perfusion aspects related to ischemic heart disease.
CONCLUSION. Radiologists should be familiar with the protocol design
and comprehensive interpretation of cardiac MDCT to provide comprehensive
treatment suggestions for the patients.
Keywords: coronary artery • ischemic heart disease • MDCT • myocardium • viability
Introduction
Cardiac MDCT has gradually become popular in recent years, but clinically
the evaluation is primarily focused on only the coronary artery
[1]. However, the literature
and our clinical experience show that many aspects of the heart can be
evaluated by MDCT in patients with suspected ischemic heart disease in
addition to coronary artery evaluation— for example, the study of the
myocardium
[2–5],
motion [2], viability
[3–5],
valves [6], and perfusion
[5].
Why Do We Need a Comprehensive Approach for Cardiac CT?
Patient 1
A 63-year-old man with a history of single-vessel disease after stenting in
the left anterior descending coronary artery (LAD) was referred for
evaluation. We found a stent in the middle LAD with total occlusion (Fig.
1A,
1B,
1C,
1D,
1E,
1F).
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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.
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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.
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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.
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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.
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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).
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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.
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Should we recommend invasive cardiac catheterization for further evaluation
and treatment?
Many radiologists would suggest catheter coronary angiography if a
hemodynamically significant stenotic lesion is seen
[1]. But in this patient, the
myocardium supplied by the LAD shows decreased perfusion with thinning. In the
delayed phase, viability imaging also showed extensive microvascular
obstruction and peripheral delayed hyperenhancement, which means the
myocardium in the LAD territory was infarcted
[3–5].
To perform cardiac catheterization and revascularize the LAD is treating only
the vascular patency, not the patient. In this patient, medical treatment for
symptoms is suggested.
Patient 2
A 68-year-old man with chest pain after exercise came to our emergency
department for evaluation. Because the ECG, creatinine kinase, and troponin I
studies were all negative, stable angina was diagnosed. MDCT was performed
before discharge. In the patient's circumflex coronary artery, we found a
totally occluded lesion (Fig.
2A,
2B,
2C,
2D,
2E).
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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.
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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.
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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).
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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.
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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.
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As a radiologist, what would you do when you see this case?
Certainly it would be correct to report a totally occluded coronary artery
lesion. But because emergent coronary intervention is indicated, it is
especially important to immediately verbally communicate the results to the
attending physician and the interventional cardiologist so that percutaneous
coronary intervention can be performed as soon as possible. The intended
discharge should be cancelled. Viability imaging shows microvascular
obstruction in the central region and viable myocardium in the periphery. This
means the patient was in the process of an acute myocardial infarction
[3–5].
If he had been discharged without intervention, the entire decreased perfusion
area would finally have become infarcted.
MDCT Weapons for Ischemic Heart Disease
Calcium Scoring
The advantage of calcium scoring is its low radiation dose
[7], no contrast medium is
needed, and the procedure is safe and quick. We can evaluate the patient's
risk of a coronary event in seconds
[7]. But the meaning of the
calcium score is epidemiologic, which means the accuracy in an individual
patient might not be good. For individual patients, the interscan variability
and possible critical stenoses in zero- or very-low-calcium-score patients are
the major limitations [8] (Fig.
3A,
3B).
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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.
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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.
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CT Coronary Angiography
Many studies have shown the high accuracy of CT coronary angiography in
identifying coronary artery stenoses
[1]. The imaging protocol and
image quality concern [9] are
also reported in many review articles. We have only two additional
recommendations. The first is that aggressive heart rate control is still
needed in most MDCT examinations. Even in high-end dual-source CT, scans
obtained during a low heart rate still have better image quality than those
during a high heart rate [10].
Second, for radiation dose control, most articles are recommending ECG pulsing
[11]. However, we think
weight-based tube-current adjustment is even more important. Thus, we use a
gradient tube current table for radiation control
(Table 1), which could
considerably reduce radiation exposure in thin patients.
If an occlusion is observed, it is important to differentiate between acute
and chronic occlusion. Chronic occlusion is easier to identify, with its focal
occlusion and good distal enhancement. The visualization of collaterals
depends on the patient's condition. If the collateral is epicardial, it is
easy to identify (Fig. 4A,
4B). But if the collateral is
intramyocardial, because of the limited contrast-to-noise ratio between the
enhanced lumen and the enhanced myocardium, collaterals usually cannot be seen
(Fig. 1A,
1B,
1C,
1D,
1E,
1F). Acute occlusion is more
difficult to interpret because it usually presents as a poorly enhanced lumen
(Fig. 2A,
2B,
2C,
2D,
2E). If no particular
attention is paid, it is easily missed as a shorter coronary branch. In
institutions that rely heavily on postprocessing technologists or automated
coronary extraction software, we recommend that the interpreting radiologists
at least scroll through the thin axial images before making a formal report.
Do not form a conclusion merely on the basis of the post-processed image.
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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.
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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).
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Arterial Phase Myocardial Assessment (Perfusion and Thickness)
For myocardial assessment, the most quiescent diastolic phase is
recommended for interpretation. We use short axes from the apex to the cardiac
base, horizontal and vertical long axes to completely evaluate the heart
[2–5].
The reason for not using the echographically frequently used four-chamber or
three-chamber view is their large interobserver variation. Using three- and
four-chamber views, it is difficult to precisely define the myocardial
segments [12]. Furthermore,
the reason for using diastole rather than systole is the poor separation of
trabeculation, papillary muscle, and myocardium during systole (Fig.
2A,
2B,
2C,
2D,
2E). Clearly identifying these
structures is important in cardiomyopathy evaluation. We emphasize that a
perfusion defect cannot help in differentiating ischemia, hibernation, and
infarction. We need myocardial thickness and viability for complete
evaluation.
Evaluation of myocardial wall thickness is of particular help to patients
with chronic myocardial infarction. In measuring the thickness, short axes are
recommended
[3–5]
because they are objective and reproducible. In patients with severe
myocardial infarction who are undergoing coronary arterial bypass grafting,
left ventricular wall evaluation is important. With the information gleaned,
surgeons can decide whether a concurrent Dor ventriculoplasty or left
ventricular aneurysmectomy should be performed.
Myocardial Motion Interpretation
The interpretation of myocardial motion should match the coronary artery
condition and myocardial perfusion to evaluate the impact of the coronary
stenosis on the myocardium. We interpret myocardial motion using terminology
already established in echocardiography, such as akinesia, hypokinesia, and
dyskinesia. With recent rapid advances in workstations, we can use serial
short axes to precisely calculate the ejection fraction
[2]. According to the blood
volume-versus-cardiac phase plot, subtle early motion abnormality such as
diastolic dysfunction could also be observed (Fig.
5A,
5B,
5C,
5D). (See
www.arjonline.org
for cine images, Figs. S5B and S5D.)
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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.
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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.
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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.
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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.
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When evaluating myocardial motion, if any valvular abnormalities such as
aortic valve stenoses or mitral tethering (Fig.
6A,
6B,
6C,
6D,
6E) are seen, they should also
be evaluated [6] because these
lesions might have symptoms similar to those of ischemic heart disease. Using
this whole-heart approach, we can still give treatment suggestions to patients
with patent coronary arteries who present with symptoms. (See
www.arjonline.org
for cine images, Figs. S6A and S6C.)
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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.
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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.
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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.
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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.
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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.
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Viability Imaging Using Delayed Phase Scanning
Viability imaging needs an additional delayed phase scan
[3–5],
but a low-dose protocol can be used. In our hospital, we use collimation of 32
x 1.25 mm, tube voltage of 80 kV, weight-based tube current selection
with ECG pulsing (70% of the R-R interval), and a 6-minute delay. The
radiation dose given is approximately 10% of that for CT coronary
angiography.
The interpretation of viability should be in agreement with the coronary
artery condition, myocardial perfusion, myocardial thickness, and left
ventricular wall motion. Myocardial conditions and their presentations are
listed in Table 2.
Miscellaneous
When a patient presents with symptoms of ischemic heart disease, sometimes
the final diagnosis is not atherosclerotic coronary artery disease. In this
situation, identifying the underlying problems and providing suggestions for
appropriate treatment are the responsibility of the radiologist (Fig.
7A,
7B,
7C,
7D,
7E,
7F). (See
www.ajronline.org
for cine images, Figs. S7B and S7E.)
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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.
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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.
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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.
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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.
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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.
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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.
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Conclusion
MDCT can potentially serve as a "one-stop shop" for the
evaluation of ischemic heart disease. Radiologists should be familiar with the
protocol design and comprehensive interpretation of cardiac MDCT to provide
complete treatment suggestions to patients.
References
- Leschka S, Alkadhi H, Plass A, et al. Accuracy of MSCT coronary
angiography with 64-slice technology: first experience. Eur Heart
J 2005; 26:1482
–1487[Abstract/Free Full Text]
- Raman SV, Shah M, McCarthy B, Garcia A, Ferketich AK. Multidetector
row cardiac CT accurately quantifies right and left ventricular size and
function compared with cardiac MR. Am Heart J2006; 151:736
–744[CrossRef][Medline]
- Mahnken AH, Bruners P, Katoh M, Wildberger JE, Gunther RW, Buecker
A. Dynamic multisection CT in acute myocardial infarction: preliminary animal
experience. Eur Radiol 2006;16
: 746–752[CrossRef][Medline]
- Lardo AC, Cordeiro MA, Silva C, et al. Contrast-enhanced MDCT
viability imaging after myocardial infarction: characterization of myocyte
death, microvascular obstruction, and chronic scar.
Circulation 2006;113
: 394–404[Abstract/Free Full Text]
- Mahnken AH, Koos R, Katoh M, et al. Assessment of myocardial
viability in reperfused acute myocardial infarction using 16-slice CT in
comparison to MRI. J Am Coll Cardiol2005; 45:2042
–2047[Abstract/Free Full Text]
- Gilkeson RC, Markowitz AH, Balgude A, Sachs PB. MDCT evaluation of
aortic valvular disease. AJR 2006;186
: 350–360[Abstract/Free Full Text]
- Rumberger JA, Simons DB, Fitzpatrick LA, et al. Coronary artery
calcium area by electron beam CT and coronary atherosclerotic plaque area: a
histopathologic correlative study. Circulation1995; 92:2157
–2162[Abstract/Free Full Text]
- Rubinshtein R, Gaspar T, Halon DA, Goldstein J, Peled N, Lewis BS.
Prevalence and extent of obstructive coronary artery disease in patients with
zero or low calcium score undergoing 64-slice cardiac MDCT for evaluation of a
chest pain syndrome. Am J Cardiol 2007;99
: 472–475[CrossRef][Medline]
- Pannu HK, Flohr TG, Corl FM, Fishman EK. Current concepts in
multidetector row CT evaluation of the coronary arteries: principles,
techniques, and anatomy. RadioGraphics2003; 23[spec no]:S111
–S125[Abstract/Free Full Text]
- Johnson TR, Nikolaou K, Wintersperger BJ, et al. Dual-source CT
cardiac imaging: initial experience. Eur Radiol2006; 16:1409
–1415[CrossRef][Medline]
- Poll LW, Cohnen M, Brachten S, Ewen K, Modder U. Dose reduction in
MDCT of the heart by use of ECG-controlled tube current modulation ("ECG
pulsing"): phantom measurements. Rofo2002; 174:1500
–1505[Medline]
- Anderson RH, Razavi R, Taylor AM. Cardiac anatomy revisited.
J Anat 2004; 205:159
–177[CrossRef][Medline]
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Abstract
Introduction
