Pictorial Essay
Cardiac Imaging
July 2008

Comprehensive Evaluation of Ischemic Heart Disease Using MDCT

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.

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 [25], motion [2], viability [35], 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).
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 [35]. 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).
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 [35]. 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).

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.
TABLE 1: Suggested ECG-Gated Cardiac CT Protocol with Weight-Based Radiation Dose Adjustment
Body Weight (kg)Actual Tube Current (mA)Effective Tube Current with Pitch of 0.2 and Rotation Time of 0.4 Second (mAs per slice)Tube Voltage (kVp)CTDIvol (mGy)
0-3140280806.0
4-6160320806.9
7-10200400808.6
11-152605208011.1
16-2010020012014.0
21-2512525012017.5
26-3015030012021.0
31-3517535012024.5
36-4020040012028.0
41-4522545012031.5
46-5025050012035.0
51-5527555012038.5
56-6030060012042.0
61-6532565012045.5
66-7035070012049.0
71-7537575012052.5
76-8040080012056.0
81-8542585012059.5
86-9045090012063.0
91-10047595012065.8
> 100
400
800
140
83.3
Note—CTDIvol = volume CT dose index.
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.

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 [25]. 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 [35] 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.)
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.)

Viability Imaging Using Delayed Phase Scanning

Viability imaging needs an additional delayed phase scan [35], but a low-dose protocol can be used. In our hospital, we use collimation of 32 × 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.
TABLE 2: Myocardial Assessment Using Comprehensive Approaches of MDCT
Myocardial Conditions in Ischemic Heart DiseaseCT Coronary AngiographyMyocardial ThicknessMyocardial PerfusionMyocardial MotionDelayed Phase
Normal viable myocardiumMostly normal or with noncritical stenosisNormalNormalNormalNormal washout pattern
IschemiaPlaque formation, stenosis, or even chronic occlusionNormalDecreased attenuation or normal (due to relative poor sensitivity of MDCT for perfusion)Decreased contractility, akinesia, or hypokinesiaNormal washout pattern
Hibernation and stunningStenosis or obvious plaque formation, sometimes with chronic total occlusionNormal or mild thinningDecreased attenuation or normal (due to relative poor sensitivity of MDCT for perfusion)Poor, probably akinetic, hypokinetic, or even dyskineticNormal washout pattern
Acute myocardial infarctionAcute occlusion with poor distal enhancementNormalDecreased attenuationPoor, mostly hypokinetic or akineticNormal washout pattern in penumbra means potentially salvageable; delayed hyperenhancement or defect means infarcted area
Chronic myocardial infarction
Stenosis or obstruction
Myocardial thinning
Decreased attenuation
Poor, could be akinetic, hypokinetic, or even dyskinetic
Delayed hyperenhancement or microvascular obstruction

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.)

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.
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.
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.
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.
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.
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).
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.
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.
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.
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).
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.
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.
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.
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.
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.
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).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.

Footnotes

Address correspondence to I. C. Tsai ([email protected]).
CME
This article is available for CME credit. See www.arrs.org for more information.

Supplemental Content

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Information & Authors

Information

Published In

American Journal of Roentgenology
Pages: 64 - 72
PubMed: 18562726

History

Submitted: December 2, 2007
Accepted: January 8, 2008

Keywords

  1. coronary artery
  2. ischemic heart disease
  3. MDCT
  4. myocardium
  5. viability

Authors

Affiliations

I-Chen Tsai
Department of Radiology, 407, Taichung Veterans General Hospital, No. 160, Section 3, Taichung Harbor Rd., Taichung, Taiwan, ROC.
Faculty of Medicine, Medical College of Chung Shan Medical University, Taiwan, ROC.
Department of Medicine, National Yang Ming University, Taiwan, ROC.
Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming University, Taiwan, ROC.
Wen-Lieng Lee
Faculty of Medicine, Medical College of Chung Shan Medical University, Taiwan, ROC.
Department of Medicine, National Yang Ming University, Taiwan, ROC.
Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming University, Taiwan, ROC.
Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan, ROC.
Chen-Rong Tsao
Faculty of Medicine, Medical College of Chung Shan Medical University, Taiwan, ROC.
Department of Medicine, National Yang Ming University, Taiwan, ROC.
Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming University, Taiwan, ROC.
Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan, ROC.
Yen Chang
Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan, ROC.
Min-Chi Chen
Department of Radiology, 407, Taichung Veterans General Hospital, No. 160, Section 3, Taichung Harbor Rd., Taichung, Taiwan, ROC.
Tain Lee
Department of Radiology, 407, Taichung Veterans General Hospital, No. 160, Section 3, Taichung Harbor Rd., Taichung, Taiwan, ROC.
Faculty of Medicine, Medical College of Chung Shan Medical University, Taiwan, ROC.
Department of Medicine, National Yang Ming University, Taiwan, ROC.
Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming University, Taiwan, ROC.
Wan-Chun Liao
Department of Radiology, 407, Taichung Veterans General Hospital, No. 160, Section 3, Taichung Harbor Rd., Taichung, Taiwan, ROC.

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