Non Invasive CT coronary artery

Imaging

Jonathan Goldin Mb.Chb.,Ph.D.

Cardio-Thoracic Radiology
Thoracic Imaging Research Group
 Introduction

● IHD
● No. 1 killer (USA)
● 50% MI- no prior history
● 68% MI- lesions stenosis <50%
●

 (Falk Circulation 95)

 Introduction

● Cholesterol established risk factor

● 35% established CAD T Chol. <250 mg/dl
 (Wald Lancet 94)
●

● 1/3 deaths CAD No conventional risk factors

 (Grover JAMA 95)
 Introduction- Aims
● Technology Review
● CAC and CAD -what is the data ?
 1. Significant CAD stenosis > 75%
 2. Early CAD
● CT angiography
●
Problems of Cardiac Imaging with CT
● CT needs multiple projections of the object at
different angles
● Finite time is required for acquisition of
projections
● Cardiac Motion changes the shape of the
object so that the projections from different
angles do not match causing image
artifacts
 CT-CAC
●

● Conventional CT
● Helical/Spiral CT

● Electron Beam CT

● Multislice CT
 EBT and Mechanical CT
EBT acquires full scan data during
period of minimum cardiac motion

Motion

Percent R-R interval

EBT 100 msec exposure
EBT & Mechanical CT
Siemens
300msec
Mechanical CT
is too slow to
be unaffected
Toshiba
by cardiac 500msec
motion

GE
700msec
 Scan Speed of EBT “Gold Standard” vs
Mechanical CT in Motion Artifacts
EBT 50 to 100 msec Mechanical CT scanners 300 to 800 msec

100 msec shutter 250 msec shutter 500 msec shutter 750 msec shutter

Motion Inhibits Coronary Calcium Detection and Scan Reproducibility

AHA statement regarding Mechanical CT: “calcified deposits are blurred due to
motion and small calcifications may not be seen.” Circulation Sept. 1996, 1175-1192
Effects of Cardiac motion
and Image Resolution
ECG Guided Image Selection
Calcification in LAD
Calcification in RCA
Radiation Dose
● Conventional CT scanning
 exposes the entire
circumference of the body to
radiation. In EBT scanning the
x-ray beam enters only from the
back.
● Anterior radio-sensitive organs
such as the breasts, thyroid
and orbits are subjected to a
much lower dose of radiation
(17% of the entrance skin
dose).
Examples of Coronary Artery Scans

NO MODERATE SIGNIFICANT
CALCIFICATION CALCIFICATION CALCIFICATION

Images courtesy of HeartScan San Frasco

 Typical Progression of Atherosclerosis

Soft plaque Plaque may Plaque ruptures Complex

grows over develop a forming a calcified “Actual
years calcified shell thrombus plaque forms cross-section”
 Calcium, Plaque and Disease
Extent
 CAC is intimately associated with plaque


● On Histology
 (Mauntner Radiology 94 and Rumberger Circulation 95)
● On Intracoronary US ( Baumgart Jam Coll Card 94)
● Heart by heart

● Vessel by vessel

● Segment by segment
Calcium, Plaque and Disease
Extent
●

● Total area CACS = Total plaque area

(R=0.90)
● Only 20% plaque area calcified (Iceberg
theory)

( Rumberger Circulation 95)
 Coronary Artery Plaque:
approximate amounts of lipid rich, fibrotic and calcified plaque

Plaque
Fibrotic &
20% Detectable
Calcified
by EBT
66%
Fibrotic
Plaque The “Tip of the
Detectable Atherosclerotic
80%
by Intravascular Iceberg”
33% Vascular
Ultrasound,
Pathology
Lipid Rich
Calcium, Plaque and Disease
Extent
● 1298 vessel segments; 50 hearts
 % Ca % Stenosis
 65 > 75
 50 51-75
 18 26-50
 1 <1
 (Mautner Radiology94)
 EBCT-CAC and Luminal
Occlusion
 CAC


● Related to luminal narrowing

● Not a measure of stenosis severity
● No value indicative of >75% stenosis
● Absence does correlate with absence site-
by-site
 (Sangiori J Am Coll Cardiol 92)
 EBCT-CAC and Luminal
Occlusion
● 95% spec. histologic and angiographic
luminal disease
● 35-88% spec angiographic narrowing
● 45-66% spec significant disease.


 (Rumberger Circulation 95; Schmermund Circ 97)


EBCT-CAC and Luminal
Occlusion
 CAC = 0


● Can be used to rule out significant

>50% stenosis (-ve pred value)
● Breen >95% (Radiology 92)

● Fallavollita 85% (Circulation 94)

● Budoff > 95% (Circulation 96)

●
 DIAGNOSTIC SENSITIVITY
NON-INVASIVE STRESS ECG $300
MODALITIES STRESS ECHO $900
STRESS THALLIUM $1,600
PET SCANNING $2,200
ELECTRON BEAM TOMOGRAPHY $400

INTRAVASCULAR ULTRASOUND $3,000

INVASIVE
MODALITIES CORONARY ANGIOGRAPHY $5,000
0% 20% 45% 60% 70% 90%

DEGREE
“THE DAWN OF A OF STENOSIS
NEW ERA” - NON-
INVASIVE CORONARY
IMAGING” R. ERBEL
 CAC by EBT and Cardiac Events
696 Patients
70
9 cardiac deaths 53 + 11 Yrs
60
22 infarctions 50% Males
50
n=64 34 revascularizations
40 2.7 year follow-up
98%
30
20
10 n=1
0 2%
Events in Patients Events in Patients
With CAC Without CAC Callister et al
ACC 3/99
Risk for a Coronary Event
696 Patients
53 + 11 Yrs
50% Males
2.7 year follow-up

Callister et al
ACC 3/99
 “Risks” For Developing Symptomatic
CAD in Middle Aged Asymptomatic Patients
Arad, Circulation, >160
June 1, 1996 (f/u 19 m)

>100
Risk Ratio

Agatston, Circulation
40 1996;94:I-360 (f/u 36-72 m)
35
30 >50
1-49
25
20
6.9
HTN TC2.7
>240 Lp(a) Smoking
10
1.8 1.9 3.6
1.2
0
Bostrum, JAMA, Framingham Data - August, 1996 f/u 15 yr.
 What does coronary calcification mean?

● Atherosclerosis present in this vessel

● Calcium volume represents one fifth the
total plaque burden
● Calcium score correlates extremely well
with coronary event risk
● If multi-vessel CAC, then risk increases
Curved MPR reformatted ● CAC tracks plaque distribution
image of Right Coronary ● Zero calcification suggests a very low
probability of obstructive disease
CT Angiography
Timing
Arterial Enhancement
 CT-Angio Advantage


 CT offers improved temporal

synchronization, spatial resolution
and higher integrity cardiac images.


 Excellent for Coronary vessel,

bypass vessels, LV wall thickness
and function, cardiac anatomy and
pericardium assessment


Collateral coronary branches

 Fast Cardiovascular
Imaging

15 cm Coverage, 1.25 mm Slice Thickness

single Breath hold
 CT Cardiovascular Imaging

● Optimized design for

Coronary Angiography
● 50-100msec image acquisition
● Prospective and retrospective
EKG gating for multiple
cardiac applications
● Advanced cardiac imaging and
analysis for unequalled
productivity
●

1.25 mm slice
17 sec. SnapShot
34 mm
 CT Cardiovascular
● Acquisition
●Prospective Gating
●SnapShot Segment

and SnapShot Burst

●Variable Scan Speed

matches rotation to
cardiac cycle
● Image Analysis
●CAC nad CACV score
●Coronary Vessel

lumen Analysis
 Coronary Vessel Analysis
Analysis Features
●

●Automatic vessel
tracking and curved-
reformat based on
simple seeding
●Optimized protocols for
Left/right & bypass
arteries
●Quantitative vessel
analysis
●diameters
●areas

●stenosis
 Cardiovascular CTA

Initial Clinical Results: Coronary Aneurysm & Stenosis

3D Coronary Angiography
Non-invasive, 3D Visualization of Coronary Artery
Bypass Grafts by EBT

Siemens MagicView
IMAGE COURTESY OF DR. ACHENBACH, ERLANGEN GERMANY
IMAGE COURTESY OF DR. ACHENBACH, ERLANGEN GERMANY
Intravenous CT Angiogram, “Normal Coronary Arteries”:
Shaded Surface Display
 Intravenous CT Angiogram, Tandem LAD Lesion:
Shaded Surface Display and Maximum Intensity Projection

Shaded Surface Display Selective Angiogram

IMAGES COURTESY OF DR. AXEL SCHMERMUND, MAYO CLINIC, ROCHESTER MN.