REVIEW ARTICLE
Recent Advances in Computed Tomographic Technology
Cardiopulmonary Imaging Applications
Azadeh Tabari, MD,*w Roberto Lo Gullo, MD,*w Venkatesh Murugan, MD,*w
Alexi Otrakji, MD,*w Subba Digumarthy, MD,*w
and Mannudeep Kalra, MD*w
Abstract: Cardiothoracic diseases result in substantial morbidity
and mortality. Chest computed tomography (CT) has been an
imaging modality of choice for assessing a host of chest diseases,
and technologic advances have enabled the emergence of coronary
CT angiography as a robust noninvasive test for cardiac imaging.
Technologic developments in CT have also enabled the application
of dual-energy CT scanning for assessing pulmonary vascular and
neoplastic processes. Concerns over increasing radiation dose from
CT scanning are being addressed with introduction of more dose-
efficient wide-area detector arrays and iterative reconstruction
techniques. This review article discusses the technologic innova-
tions in CT and their effect on cardiothoracic applications.
Key Words: chest computed tomography, cardiopulmonary,
advances
(J Thorac Imaging 2017;32:89–100)
S ince its invention in 1971, technologic advances in
computed tomography (CT) have expanded its appli-
cations in the chest and heart. In the past 20 years, the
number of CT examinations has increased by about 10%
annually. Advances in hardware as well as in image
reconstruction and processing have enabled faster scanning
at lower radiation dose for contemporary multidetector-
row CT (MDCT) scanners. Hardware advances in CT
technology have resulted in the introduction of several new
MDCT scanners with incremental capabilities of greater x-
ray tube power, faster gantry rotation times, wide-area and
dose-efficient detector array systems, as well as dual-energy
capabilities with single-source, twin-beam, and sandwich
layer detector systems. The most notable software advances
have come in the form of dual-energy image processing,
iterative reconstruction, and automatic kV selection tech-
niques, which have proven to be key in several emerging
and established indications for cardiothoracic imaging. We
review recent technologic advances in CT and literature
pertaining to their role in cardiothoracic imaging.
RECENT ADVANCES IN CT TECHNOLOGY
In this section, we discuss advances in the hardware
and software aspects of CT technology. Improvements in
From the *Department of Imaging, Massachusetts General Hospital;
and wHarvard Medical School, Boston, MA.
The authors declare no conflict of interest.
Correspondence to: Azadeh Tabari, MD, Department of Imaging,
Massachusetts General Hospital, Boston, MA 02114 (e-mail:
atabari@mgh.harvard.edu).
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/RTI.0000000000000258
J Thorac Imaging  Volume 32, Number 2, March 2017
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
CT hardware include changes in x-ray tube power, detector
elements, scanning speed, and dual-energy scanning capa-
bilities. Software advances have been led by introduction of
iterative reconstruction techniques (IRTs) that allow radi-
ation dose reduction and/or image quality improvement.
X-Ray Tube Capabilities
Modern MDCT scanners enable faster scanning,
which require delivery of higher tube current over short
scanning time. Previous CT scanners were limited in their
ability to quickly dissipate the heat generated in the x-ray
tubes, as production of x-rays is an inefficient process.
Almost 99% of the incident electrons at the anode are
either scattered or contribute to heat generation within the
x-ray tube. The reduced gantry rotation time in modern-
day CT scanners (for rapid scanning) is another major
factor for need of powerful x-ray tubes.1 Increasing the
x-ray tube power leads to overheating of the tube.
One vendor has updated its x-ray tube (Performix;
GE) for efficient heat dissipation during scan acquisition
with an efficient electron collector system. To overcome the
scattered electrons that impinge on the x-ray tube wall,
electron collector systems have been introduced in the past.
These systems consist of an anode and a cathode assembly
designed in such a way as to collect and deflect the scattered
electrons. The strategies to be employed for heat dissipation
from the electron collector include using chambers of cir-
culating coolant fluid and increasing the area over which
the collected electrons are swept over by increasing the
coiling in the collector. Effective heat dissipation ensures
minimal off-focal radiation and enhanced tube life.2
Some new x-ray tubes (iMRC; Philips) have improved
anode bearings and coolant system to decrease tube over-
heating. This new tube is purported to have higher focal
spot power density and a current density of over 1 A/mm2
to ensure that the energy of the emitted photons is relatively
close and reduces image noise. The unipolar high-voltage
supply used in this tube helps in efficient cooling of the
anode (the cathode is held at earth potential; hence the
majority of heating occurs at the anode, which is taken care
of by the newer cooling elements).3
Some new x-ray tubes (Vectron; Siemens) enable the
use of substantially higher–tube-power CT scanners
(2 1300 mA). This enhanced power is extremely important
in the context of dual-energy CT acquisitions to generate an
x-ray flux of adequate power at low values of tube potential
(the least possible is 70 kV). Another important require-
ment in dual-energy CT is the spectral separation of the
acquisitions to sufficiently differentiate structures based on
attenuation characteristics at differing values of tube volt-
age. The improved photon separations ensure that spectral
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Tabari et al
overlap is minimal, thereby achieving better contrast. Some
of the modern CT systems now allow tube potential to up
to 70 kV, which helps achieve both contrast volume and
radiation dose reductions.4
The Toshiba x-ray tubes (MegaCool) use a copper
alloy to absorb recoil electrons and reduce unwanted off-
focal x-rays. Additional features minimize focal spot
movement with bearing supports at both ends of the anode
axis (www.toshibamedicalsystems.com/products/dose/low
dose/hardware.html#hardware01).
Changes in Detector Elements and Shorter
Scan Times
Innovations in detector capabilities in CT have
resulted in improved scan coverage per gantry rotation, and
detector efficiency. Although the detectors used in clinical
CT systems have not become finer than 0.5 mm along the
z-axis in the last decade, the detector width along the z-axis
has increased markedly. Development in wide-area detec-
tors enabling >40-mm coverage per rotation was led by the
320-section MDCT with 0.5-mm detector row-width from
Toshiba, enabling up to 16 cm per gantry rotation.
Recently, Philips and GE introduced scanners with 128 and
256 detector rows enabling 8- and 16-cm coverage, respec-
tively, with 0.625-mm individual detector row-width.
Siemens’ new third-generation dual-source CT scanner has
a 6-cm detector (96 rows 0.6-mm detector row-width for
each detector array) width but enables fast scan coverage
due to use of double helices and higher pitch values owing
to the presence of 2 x-ray tubes and detector arrays.
Wide-area detectors (4 to 16 cm) help in faster cover-
age through the heart in fewer cardiac cycles and with less
slab artifacts. In fact, the 16-cm MDCT scanners (with 256
to 320 detector rows) enable imaging of the entire heart in a
single gantry rotation and cardiac cycle. With single rota-
tion coverage of the heart, there are no slab artifacts
associated with the use of smaller detector area MDCT that
need >1 heart beat to cover the entire coronary arterial
circulation even in patients with higher or irregular heart
rates, with less radiation burden to patients. For patients
with lower heart rate (typically 65 bpm or under), the dual-
source MDCT scanners can also image the entire heart with
a high nonoverlapping pitch of up to 3.4:1 in a single heart
beat.
There have been improvements in detector efficiency.
For example, the gemstone detectors (garnet-based detec-
tors) from 1 vendor (GE Healthcare) enable faster scanning
and kV switching, which enables the scanner to acquire
dual-energy data sets. These detectors have four times
faster recovery time compared with some other detectors.
Another vendor (Siemens) utilizes an ultrafast ceramic
material (gadolinium oxysulfide) in its detectors, which
have a faster recovery time as well. Philips’ nanopanel
spherical detector technology maintains electrical con-
tinuity along the edges of the detector elements to decrease
the gaps between individual detector rows, which results in
loss of image quality in the conventional CT detectors. This
technology allows the edges to contribute to signal from
adjacent detector elements.
Concomitant improvements in data acquisition sys-
tems have resulted in improvement in CT radiation dose
efficiency. For example, the stellar detector (Siemens)
reduces electronic noise by combining an analog digital
converter chip with the photodiode into 1 chip to generate a
direct digital signal. In conventional CT detectors, the
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J Thorac Imaging  Volume 32, Number 2, March 2017
scintillator, analog digital converter, and photodiode are
separate components, which results in higher electronic
noise. Another vendor (GE) has introduced miniaturized
detector modules to reduce electronic noise by 25% to
improve image quality and reduce artifacts from low-signal
conditions (such as a very low dose or a very large patient).
Along with increase in detector width in the z-axis,
there has also been some improvement in the gantry rota-
tion speed in all modern MDCT scanners, both of which
facilitate faster scanning. The new wide-area detector CT
(GE Revolution, 2560.625 mm) comes with a 280-ms
rotation time, capable of scanning up to 16 cm in 1 gantry
rotation. The third-generation dual-source CT (Force,
Siemens) is equipped with a 6-cm detector width but a
faster 250-ms rotation, which gives a 66-ms temporal res-
olution for cardiac CT. Improvement in temporal reso-
lution of MDCT scanners now enables coronary CT
angiography in patients with rapid and irregular heart
rates.5,6
Caruso et al7 have demonstrated that technologic
advances in CT help in evaluation of cardiac function.
Ability to image the entire heart in 1 cardiac cycle with a
wider-area detector (256 to 320 detector rows) MDCT, with
or without faster temporal resolution of dual-source
MDCT, also enables dynamic CT myocardial perfusion
imaging to distinguish between reversible and irreversible
hypoattenuating myocardial perfusion defects. Wide-area
detector CT and those with fast acquisition times also help
in optimal evaluation of the entire thoracoabdominal aorta
including the femoral arteries for planning of percutaneous
transfemoral aortic valve replacements without the need for
a large volume of intravenous contrast medium.8
Faster scanning is advantageous for avoiding motion
artifacts in children with suspected or known congenital
cardiac abnormalities. Koplay et al9 have reported that use
of prospective ECG-gated high-pitch dual-source MDCT in
pediatric congenital cardiovascular abnormalities provides
acceptable image quality at very low radiation dose.
Automatic Exposure Control (AEC) and
Automatic kV Selection
AEC techniques have been in use in MDCT scanners
for more than a decade. Several studies have reported
advantages of AEC over use of fixed tube current10 for
radiation dose optimization in chest CT scanning.
Recently, some vendors (ie, GE, Siemens) released
organ-based tube current modulation (OBTCM).3,4 This
technique enables users to reduce the radiation dose to
radiosensitive organs such as the thyroid gland when per-
forming chest CT. Most radiation to these anteriorly
located organs in supine patients results when the x-ray
tube is anterior to the patient. The OBTCM turns off the x-
ray tube during a part of the gantry rotation to reduce the
radiation dose to these sensitive organs while increasing the
tube current in the remaining projection to maintain con-
stant image quality.
A recent study involving 1263 women undergoing
chest CT reported that OBTCM can help in significant
reduction in radiation dose (up to 16%) to the breast
compared with constant tube current, although a sub-
stantial portion of the breast may lie beyond the region of
dose reduction with OBTCM.11
With the availability of higher-power x-ray tubes capable
of operating at higher tube current, there has been an increase
in the use of lower kV for performing contrast-enhanced CT.
J Thorac Imaging  Volume 32, Number 2, March 2017
Some vendors (CarekV, Siemens; kV Assist, GE) have
released automatic kV selection techniques that allow the
scanners to automatically select the most optimal kV based on
specified CT examination (for example, noncontrast, post-
contrast, or CT angiography protocol) and size estimation of
the patient from the planning radiograph. These techniques
help maintain or improve the contrast-to-noise ratio of the
images while maintaining or reducing radiation dose. Several
recent studies have noted a reduction in radiation dose with
the application of these techniques.12,13 Although most
MDCT scanners allow the selection of 3 to 4 different kV (80
to 140 kV at increments of 20 kV) for CT scanning, some
recent MDCT scanners (eg, Force; Siemens) allow a wider
selection of kV (70 to 150 kV at increments of 10 kV) for use
with the automatic kV selection technique.
Solutions for Irregular Heart Rate
Several vendors have introduced specific software
algorithm to address the issue of irregular heart rate in
cardiac CT. One vendor utilizes the Snapshot freeze tech-
nique (GE), which uses information from adjacent cardiac
phases within a single cardiac cycle to characterize and
compensate for coronary motion. The technique estimates
the motion pathway of the coronary arteries and velocity
from adjacent cardiac phases to determine the expected
target phase for each vessel. Another vendor has introduced
an advanced arrhythmia rejection or compensation algo-
rithm (Adaptive Cardio Sequence; Siemens) for compen-
sating gradual changes in heart rate during cardiac CT.
During ectopic beat or widely irregular rhythm, this algo-
rithm automatically pauses the scanning and scans the
patient at the same table position once the cardiac rhythm
has become regular.14
IRT
Image reconstruction for x-ray CT can be generally
classified into 2 major categories: analytical reconstruction
and iterative reconstruction.15 The analytic reconstruction
techniques based on filtered back projection (FBP) make
several presumptions to expedite image reconstruction,
which are prone to increased image noise and artifacts,
particularly at low radiation doses. In contrast, IRTs
(Table 1) create images based on repetitive cycles of com-
parison between the calculated projection data and an
estimated data set using actual projection data sets and
accurate scanner properties. This enables the IRTs to
reduce image noise and improve image quality, which in
turn allows users to reduce the radiation dose.16 Two broad
categories of IRTs in commercial use include pure and
hybrid IRTs. The latter involve blending of IRT data sets
with FBP to maintain image noise and appearance similar
to that of FBP-based images.17 Hybrid IRTs are the most
commonly used techniques in contemporary MDCT scan-
ners as they are much faster and similar in appearance to
conventional FBP images as compared with pure IRT.
Although pure IRTs (such as GE Veo) have greater noise
reduction and artifact suppression capabilities, these tech-
niques are computationally intensive, taking several
minutes to reconstruct a single image series, and result in
images with distinct image appearance.
Most IRTs come with a menu of options for use of
IRT, which may be on a percentage scale (such as 0% to
100% with steps of 10% for ASiR; GE) (Fig. 1), categories
(such as weak, standard, and strong for AIDR 3D; Tosh-
iba) (Fig. 2), and nominal scale (such as strength of 1 to 5
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
Recent Advances in CT Technology
TABLE 1. Commonly Used Iterative Reconstruction Algorithms
Commonly Used by the Vendor
Adaptive statistical iterative reconstruction GE Healthcare
Model-based iterative reconstruction GE Healthcare
Sinogram-affirmed iterative reconstruction Siemens
(SAFIRE) Healthcare
Adaptive iterative reconstruction 3D Toshiba
(AIDR 3D) Healthcare
iDose4 Philips
Healthcare
with steps of 1 for SAFIRE and ADMIRE; Siemens; 1 to 7
with steps of 1 for iDose; Philips) (Figs. 3, 4). With
increasing strength of IRTs, there is greater image noise
reduction and variable change in image appearance. Con-
sequently, lower radiation dose or larger subjects may need
higher strength of IRT as compared with CT examinations
at higher dose or in smaller subjects.
Although there are plenty of studies comparing dif-
ferent IRTs,18–35 there is no consensus on the best IRT and
its settings for different patient types and clinical indica-
tions. A recent meta-analysis on IRT reported the potential
for radiation dose reduction with improved image quality
compared with FBP-based image reconstruction.23 Several
studies from multiple vendors demonstrate that it is possi-
ble to reduce radiation dose below 1 mSv for IRT-enabled
chest CT for evaluation of lung nodules and for lung cancer
screening.19 In fact, some studies have reported the possi-
bility of reducing the radiation dose for evaluation of lung
nodules to <1/10th of a mSv with use of IRT.20 High
inherent tissue contrast between the pulmonary nodules
and the air-filled lungs help reduce radiation dose for chest
CT even with FBP techniques, but availability of IRT has
helped denoise the images further compared with FBP and
also reduce some artifacts related to extremely low–
radiation-dose scanning. Radiation dose reduction has
also been reported for evaluation and quantification of
emphysema using IRT.21 For CT angiography studies of
coronary arteries as well as other thoracic vessels (pulmo-
nary arteries, pulmonary veins, and aorta), noise reduction
capabilities of IRT have enabled increasing use of lower
kV, which helps improve the image contrast while offering
opportunities for reducing the injected contrast volume.22
In our practice most CT angiography studies in the thorax
are now performed at 80 to 100 kV using IRT. Use of
higher kV (120) can be limited to larger or obese patients.
Along with the benefits of IRTs for image quality
improvement at low radiation dose, it is important to
realize that there are some trade-offs associated with
IRTs.23,24 These include change in image appearance and
blocky appearance of structures on IRT images as com-
pared with those in conventional FBP. Some prior patient
studies have reported loss of visibility of lung fissures with
use of IRTs, although the detection and conspicuity of lung
nodules and abnormalities was unaffected.24 Finally,
although sub-mSv radiation doses are achievable with IRTs
for lung nodule follow-up and lung cancer screening, non-
pulmonary soft tissues (such as mediastinal or chest wall
soft tissues) are often limited at such doses despite high-
strength IRTs.25 These caveats imply that IRTs must be
“fine-tuned” for individual practices, preferences, and
clinical protocols. A recent study of 4 different CT vendors
has reported up to about 10% to 60% noise reduction with
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Tabari et al J Thorac Imaging  Volume 32, Number 2, March 2017

SD-FBP SubmSv-FBP SubmSv-ASIR70 SubmSv-VEO

CTDIvol 13 mGy CTDIvol 0.5 mGy CTDIvol 0.5 mGy CTDIvol 0.5 mGy

A B C D

FIGURE 1. Transverse chest CT images of a 71-year-old male patient depict a right upper-lobe solid noncalcified lung nodule (arrow) in
(A) standard FBP (CTDIvol*, 13 mGy), reduced-dose FBP (CTDIvol, 0.5 mGy) (B), ASIR (CTDIvol, 0.5 mGy) (partial IRT at 70% blending)
(C), and VEO (CTDIvol, 0.5 mGy) (full model–based IRT) (D) images. *CT Dose Index Volume. ASIR indicates adaptive statistical iterative
reconstruction; VEO, valence electron only.

5 different IRTs when CT scanning was performed in the
dose range of 1.3 to 1.5 mGy.26 In our institution, most
cardiothoracic CT examinations are performed with about
40% to 50% strength of ASiR (GE), S2 or S3 strength of
SAFIRE (Siemens), or iDose 2 or 3 (Philips) to avoid
undue change in image appearance relative to FBP.
Spectral CT Technology
CT attenuation characteristics of tissues vary with the
energy levels of incident photons. The same tissues can have
different attenuation characteristics at differing values of photon
energies. With dual energy CT (DECT), the scanner acquired
additional information from interactions between the tissues and
x-rays, which include photoelectric absorption and Compton
scattering. Photoelectric effect is the process of displacement of
the electrons from the innermost shell when an incident photon
with energy higher than a certain threshold strikes the atom. The
displaced electrons are then replaced by electrons from outer
energy levels, producing characteristic radiation. The latter
depends on the effective atomic number and the electron density.
At higher x-ray energy levels, the most common
interaction involves transfer of x-ray photon energy to
electrons in the outer shells and change in the direction of
x-ray photons (Compton scattering). At lower x-ray photon
energy, photoelectric absorption is much higher. In dual-
energy CT, the differential interactions of 2 x-ray energies
form the physical basis for decomposition of images into
2-basis materials (eg, iodine-calcium, iodine-water, and
calcium-water) as long as their atomic numbers are not the
same.

SD-FBP SubmSv-AIDR3D SubmSv-AIDR3D

9.7 mGy 1.1 mGy 0.5 mGy

A B C

FIGURE 2. Transverse chest CT images of a 69-year-old female patient scanned at 3 different dose levels (CTDIvol,* 9.7, 1.1, and
0.5 mGy, respectively). Tiny pulmonary nodule in the left lower lobe (arrow) is equally well seen on FBP (9.7 mGy) as on reduced-dose
AIDR 3D (1.1 and 0.5 mGy) images. *CT Dose Index Volume. AIDR 3D indicates adaptive iterative dose reduction.

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J Thorac Imaging  Volume 32, Number 2, March 2017 Recent Advances in CT Technology

SD-FBP SubmSv-FBP SubmSv-Safire level2 SubmSv-Safire level3 SubmSv-Safire level4

CTDIvol 6 mGy CTDIvol 0.4 mGy CTDIvol 0.4 mGy CTDIvol 0.4 mGy CTDIvol 0.4 mGy

A B C D E

FIGURE 3. SAFIRE versus FBP images of a 67-year-old male patient who underwent standard (6 mGy) reduced-dose chest CT (CTDIvol*,
0.4 mGy). Transverse chest CT images at standard dose (FBP, A), and reduced dose (FBP [B], SAFIRE [level 2] [C], SAFIRE [level 3] [D],
and SAFIRE (level 4) [E]) demonstrate the left lower lobe pulmonary nodule (arrow) equally well along with other anatomic details of the
lungs. *CT Dose Index Volume.

Different vendors use different proprietary methods to
acquire DECT data. The rapid kV switching (GE) method
uses a single x-ray tube with rapidly alternating voltage
(< 0.5 ms) between 2 values to generate projection images
from x-rays of different energies. This technique only ena-
bles 140 and 80 kV settings with fixed tube current. The
exposure time is adjusted in such a way that the 80 kV
projection accounts for 65% and the 140 kV projection
accounts for 35%. As the kV switching happens in a very
short duration, the projection data are treated as coinci-
dental both temporally and spatially.27,28 This allows for
calculation of material density, which is unique to single-
source (rapid kV switching) DECT scanning. On the other
hand, AEC cannot be used with rapid kV switching.
Instead, users have to select a vendor-specified fixed tube
current preset based on the body region, which can increase
the radiation dose associated with this technique of DECT
as compared with single-energy CT.
Dual-source MDCT (Siemens) scanners use 2 separate
x-ray tubes and detector assemblies to generate 2 different
projection data sets. These 2 data sets are acquired with a
very small difference in acquisition time (usually 75 or
83 ms). It is possible to have better control over radiation
dose with this technique as AEC can be used for individual
tubes separately. Prior studies have shown that DECT
performed with this technique is dose neutral to single-
energy CT.29,30 As one detector assembly is smaller than the
other, the field of view is rather limited (about 33 to 35 cm)
for DECT. With adequate centering, the entire lungs can
generally be included in this field of view. The limitation of
field of view does not apply to a recently introduced twin-
beam dual-energy technology (Siemens) to acquire DECT.
This technology entails the creation of 2 x-ray spectra from
a single x-ray source with 2 different materials’ filter (gold
for low-energy x-ray spectrum and tin for high-energy x-ray
spectrum) before reaching the patient. Full 50-cm field-
of-view DECT and AEC are possible with this technique.
Layered detector systems (sandwich detectors; Philips)
involve spectral separation at the detector level with a single
x-ray tube. In these detectors, scintillators of varying pho-
ton sensitivity are stacked in layers and are used for
resolving spectral differences and to generate DECT pro-
jection data. This method permits the use of AEC with
DECT scanning. As the technique does not require

SD-FBP SubmSv-IMR SubmSv-iDose SubmSv-IMR SubmSv-iDose

CTDIvol 5.7 mGy CTDIvol 0.9 mGy CTDIvol 0.9 mGy CTDIvol 0.4 mGy CTDIvol 0.4 mGy

A B C D E

FIGURE 4. Ground-glass nodule in the right upper lobe (arrow) is equally well seen on transverse chest CT images of an 87-year-old
male patient reconstructed with FBP (CTDIvol*, 5.7 mGy [A]), as well as reduced dose IMR (0.9 mGy [B], 0.4 mGy [D]) and iDose
(0.9 mGy [C], 0.4 mGy [E]). *CT Dose Index Volume. IMR indicates iterative model reconstruction, iDose iterative reconstruction.

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Tabari et al
modification in acquisition protocols, all CT examinations
on these scanners have DECT data sets.31
Most vendors allow application of IRT on the DECT
image data sets to improve image quality. Two standard
approaches have been used for the generation of DECT
images. In the first method of raw data processing (GE),
corresponding projections are subtracted, and the differ-
ence is reconstructed using FBP to generate the DECT
images. The image domain method (Siemens) involves
generation of standard CT images and then uses the dif-
ferences in Hounsfield units from corresponding voxels to
generate the DECT images.32
There are over 15 different types of DECT image-
processing algorithms, with the most common being opti-
mization, differentiation, and quantification algorithms. In
optimization algorithms (used to generate virtual mono-
energetic images), the density of voxels in Hounsfield units
at the 2 energy levels is used to extrapolate and produce
images at the specified virtual monoenergetic levels (40 to
190 keV). The low keV images (such as 40 to 60 keV) have
better contrast (especially good for CT angiography). The
high keV images (such as >100 keV) have lower noise and
less contrast streaking artifacts.33 Virtual monoenergetic
images can be obtained with either image-domain or
projection-domain methods.34,35
Differentiation algorithms are used to differentiate
structural constituents of a voxel. In this method, a slope of
the densities (in HU) at the 2 x-ray energy levels is used as
the basis for differentiation of 2 substances. In other words
densities above and below the slope are color coded for the
purpose of differentiation. The resultant data sets provide
virtual noncontrast images (with subtraction of iodine from
the other tissues) or iodine or contrast-enhanced image
(with subtraction of water-based soft tissues from iodine-
enhanced tissues). The iodine map images can help deter-
mine iodine-based contrast enhancement in different tis-
sues; for example, with the pulmonary blood volume
application mode 1 can assess the pulmonary parenchymal
enhancement (similar to perfusion images from the nuclear
perfusion scan).36 Quantification algorithms typically use 3-
material decomposition, where 1 material is quantified on
the basis of 2 previously defined slopes based on density
differences. The materials for the quantification usually are
the intravenous contrast agents. For example, in the lungs
(soft tissue, air, and iodine-based intravenous contrast), the
differences in densities between air and soft tissue at the 2
energy levels are interpreted as displacement along the
second slope (iodine). These deviations are color coded to
reveal relative concentration of iodine in the voxel. Whereas
optimized algorithms generate gray-scale images, the other
2 algorithms generate color-coded images.
CT-based Fractional Flow Reserve (FFR)
In patients with moderate luminal narrowing, the FFR
estimated from invasive coronary angiography can help
determine the hemodynamic significance of coronary artery
stenosis and in making decisions regarding revasculariza-
tion (such as insertion of coronary stents). The FFR rep-
resents the ratio of average coronary artery pressure distal
to stenosis to the average thoracic aortic pressure measure
during highest coronary blood flow. The importance of
FFR has been recognized in several studies.37
Noninvasive estimation of FFR (CT-FFR) can be
derived from CCTA data using concepts of fluid dynamic
modeling.38 CCTA and CT-FFR can provide combined
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J Thorac Imaging  Volume 32, Number 2, March 2017
anatomic information on coronary artery stenosis and
functional significance of coronary lesions without the need
for additional image acquisition, radiation burden, or
administration of contrast agent.39,40 Although the accu-
racy of CT-FFR versus FFR estimated from invasive cor-
onary angiography has been established in prior multi-
center studies,41–43 the current implementation of CT-FFR
requires a pristine CCTA data set and long computational
time.
APPLICATIONS IN CARDIOTHORACIC IMAGING
Coronary CT Angiography in High Heart Rates
and Heart Rate Variability
Faster acquisition times with modern MDCT allow for
good image quality in patients with high heart rate or
arrhythmia. Previously, these patients were scanned with
retrospectively gated CCTA, but this was associated with a
relatively high radiation dose. With the new-generation
scanners and suitable reconstruction methods, diagnostic-
quality CCTA can be obtained in such patients without
substantial increase in radiation dose. For example, recent
studies have reported that diagnostic-quality prospectively
triggered CCTA can be obtained with 320–detector-row
MDCT (scan coverage of 16 cm per gantry rotation allows
imaging of the whole heart in a single heart beat) in patients
with chronic atrial fibrillation as compared with CCTA in
patients with regular heart rhythm.34 Compared with a 16–
detector-row MDCT, the 320–detector-row MDCT pro-
vided far superior results in patients with chronic atrial
fibrillation.35 Another study performed on coronary artery
bypass grafts using a 256-slice MDCT scanner has reported
that graft image quality is not influenced by the absolute
heart rate but it was influenced by heart rate variability
Z1 bpm.36 In this study, a total of 78 patients with
254 coronary artery bypass grafts (762 graft segments)
were scanned with 270-ms rotation, prospectively
electrocardiogram (EKG)-gated 256–detector-row MDCT
scanner. Diagnostic quality was limited in only about 4%
of coronary segments, as compared with 22% reported for
16– and 64–detector-row MDCT.44 Likewise, other studies
have also reported that newer MDCT scanners have the
potential to detect coronary arterial stenosis of >50% and
>75% in patients with high (> 65 bpm) or irregular heart
rates with the same image quality of patients with lower and
regular heart rhythm of <65 bpm.45
Another study with a single-source, 256-slice MDCT
(Brilliance iCT; Philips Healthcare) has reported no com-
promise in the diagnostic accuracy of coronary CTA per-
formed without beta blockers for heart rates Z90 bpm.5
On third-generation dual-source 192–detector-row
MDCT scanners, recent studies have reported the feasibility
of prospectively triggered, high-pitch protocols (up to 3.2:1)
for evaluating coronary arteries in heart rates of up to
70 bpm regardless of the presence or absence of heart rate
variability.46 On previous generations of dual-source
MDCT scanners, this scanning mode with high pitch was
limited to patients with lower heart rate (typically
<65 bpm) and lower heart rate variability.47,48
The other technique of step and shoot or nonhelical
mode of acquisition of prospectively triggered CCTA is also
being increasingly used in patients with higher or irregular
heart rate. An advanced arrhythmia rejection algorithm has
been used in conjunction with prospectively EKG-triggered,
J Thorac Imaging  Volume 32, Number 2, March 2017
axial CCTA in patients with ectopic or widely irregular
heart rhythm to compensate for changes in the heart rate
and repeat scanning over the scan position affected by these
fluctuations in heart rhythm.49 A recent study has reported
that use of arrhythmia rejection algorithm (Adaptive Cardio
Sequential Flex mode; Siemens) with prospectively EKG-
triggered axial CCTA in end-systolic phase provides better
diagnostic quality as compared with imaging in diastolic
phase.50
Another vendor uses Snapshot Freeze (GE) to reduce
the effect of cardiac motion on the ability to visualize cor-
onary arteries. This technique enabled an improvement in
image quality and interpretability of CCTA in patients
scanned with prospectively EKG-triggered CCTA as well as
retrospectively gated CCTA examinations.51
Cardiothoracic CT at Reduced Radiation Dose
As stated in prior sections, thoracic CT applications
have benefitted in terms of radiation dose reduction with
availability of IRTs. In fact, pulmonary nodule follow-up
CT and low-dose CT for lung cancer screening can now be
performed at radiation doses well under 1 mSv with use of
these reconstruction techniques.
Several technologic innovations described in prior
sections have enabled dose reduction for CCTA as well.
CCTA has emerged from being one of the highest–
radiation-dose CT examinations to one among the
lowest–radiation-dose examinations, thanks to these
advancements.
Compared with the retrospectively gated CCTA in
which the x-ray tube is always on during the entire duration
of the cardiac cycle(s) over the scan acquisition period, with
prospectively triggered CCTA the x-ray tube is switched off
during certain periods of the cardiac cycle (systole or dia-
stole) to reduce radiation dose. With prospectively triggered
EKG-gated CCTA, it is possible to reduce the radiation
dose by up to 70% as compared with the retrospectively
gated CCTA for evaluation of coronary arteries (Fig. 5).52
A recent study in 150 patients (with heart rate >75 bpm)
undergoing CCTA has shown that prospectively triggered
CCTA in end-systole can provide diagnostic quality in
patients with high heart rate as in such patients the diastolic
period is substantially smaller while the systolic period of
cardiac cycle remains relatively unchanged.
Increased use of 80 to 100 kV for CCTA as described
above has enabled substantial radiation dose reduction as
compared with 120 kV.39,53 Prior studies have reported a
31% to 38% dose reduction at 100 kV compared with
120 kV without compromising the image quality and the
rate of diagnostic examinations.40 CCTA at 80 kV has also
been reported extensively in the literature, particularly in
nonobese patients,54,55 with up to 70% decreased radiation
dose at 80 kV compared with CCTA at 120 kV.56 Use of
lower kV helps reduce radiation dose with preserved
interpretability, but with an increase in image noise, which
can limit its use particularly in obese or larger patients
without associated increase in the tube current to offset the
increase in image noise associated with lower kV. Avail-
ability of more powerful x-ray tubes (eg, in third-generation
dual-source MDCT [Force; Siemens]) with tube currents up
to 1300 mAs at tube voltages of 70 kV has further expanded
the use of lower kV for CCTA. Recent studies have
reported that 70 kV at 450 mAs can substantially reduce the
radiation dose while maintaining the diagnostic quality of
CCTA in 92% of patients below 100 kg and with a regular
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
Recent Advances in CT Technology
heart rate of <60 bpm.57 With the application of IRT
(ADMIRE; Siemens), diagnostic quality was further
increased to 96% of patients. Indeed, IRTs have been
shown to decrease image noise in CCTA compared with
FBP algorithms, thereby offering diagnostic quality in low-
dose CCTA protocols.54
Contrast Volume Reduction for Cardiothoracic
CT
Contrast volume reduction for CT scanning may be
important for patients with compromised renal functions in
whom noncontrast CT or other imaging modalities may not
provide information that a contrast-enhanced CT scan can.
As scanners have become faster with dual-source or wide-
area detectors, there has been a decrease in contrast volume
requirement for CCTA. Furthermore, increased use of
lower kV (r100 kV) can enable reduction in rate and/or
volume of injected contrast volume for both chest and
cardiac CT angiography examinations. Cakmacki et al have
reported the use of 40 mL of contrast material for combined
CT angiography of pulmonary arteries and the thoracic
aorta at 80 kV in patients with high risk for contrast-
induced nephropathy.58,59 The study was performed with a
128-section MDCT (Siemens Definition AS + , Siemens
Medical Solutions, Forchheim, Germany); the reported
tube current was 150 effective mAs.
Faggioni and colleagues have reported that 40 mL of
320 mg iodine/mL contrast material at 80 kV can provide
similar contrast enhancement for CTA of pulmonary
arteries as compared with a similar volume of 400 mg
iodine/mL contrast material. The study was performed with
a commercially available 64-MDCT scanner (LightSpeed
VCT; GE Healthcare). Scanning parameters reported
included tube voltage of 80 kV, tube current modulation of
50 to 300 mA, detector configuration of 64 0.625 mm,
beam pitch 0.984:1, and tube rotation time of 0.5 s.59,60
A study by Wuest et al evaluated the aortic root
anatomy and vascular function using ECG-triggered high-
pitch (pitch = 3.4) spiral dual-source CT with minimized
(40 mL) volume of contrast agent. The scanner used was a
second-generation dual-source CT system (Somatom Defi-
nition Flash; Siemens Healthcare, Forchheim, Germany).
This study showed that high-pitch protocol allowed for
preprocedural CT evaluation of TAVI with low volume of
contrast agent while preserving the diagnostic image
quality.61
Compared with legacy MDCT scanners (eg, 4–
detector-row MDCT) requiring up to 140 mL of contrast
volume for CCTA, 80 to 100 mL contrast volume is suffi-
cient for 64-MDCT, and <80 mL contrast volume is
practical for more advanced MDCT scanners.38,61 Recent
studies suggest that injection protocols with contrast vol-
umes of about 40 to 50 mL can provide sufficient coronary
arterial enhancement for CTCA on 64-MDCT62,63 and 320-
MDCT.64
On dual-source CT as well as wide-area detector CT
(such as 256 or 320 detector rows), the ultrashort acquis-
ition time helps reduce the volume of contrast material for
diagnostic opacification of coronary arteries. Effect of
lower contrast volume on image quality with high-pitch,
prospectively EKG-triggered dual-source MDCT of the
coronary arteries has been reported in prior studies; coro-
nary attenuation cutoff limit of 300 HU in coronary arteries
can be obtained with 30 mL in women and with 40 mL of
contrast material in men.65 However, use of such low
www.thoracicimaging.com | 95
Tabari et al J Thorac Imaging  Volume 32, Number 2, March 2017

FIGURE 5. An 81-year-old man underwent CT angiography of the heart and the thoracoabdominal aorta to assess for feasibility of
percutaneous transfemoral aortic valve replacement on a second-generation dual-source 128-section multidetector-row CT. The aortic
root and heart were imaged with systolic prospectively triggered EKG-gated technique while the remainder of the thoracoabdominal
aorta was assessed with high-pitch scanning (pitch 3.2:1). Transverse image (A) demonstrates aortic valve and coronary artery calci-
fication. The volume-rendered image (B) demonstrates scattered atherosclerotic disease of the thoracic and abdominal aorta with a
small sacular aneurysm of the distal abdominal aorta.

contrast volume with this technique is limited to patients
with low heart rates (< 65 to 70 bpm) in whom high-pitch
prospectively EKG-triggered CCTA can be performed with
acceptable diagnostic accuracy.
Availability of algorithms for use of lower kV in
CCTA as well as automatic kV selection techniques also
enable reduction in contrast volume for CCTA. Most
patients with body mass index r30 kg/m2 can be scanned
at 80 to 100 kV for CCTA, which can facilitate the use of
lower contrast volume in these patients. Use of lower kV
not only improves the image contrast but also helps reduce
the radiation dose with CCTA. Although most scanners
enable up to 80 kV as the lowest tube potential, some
scanners now enable scanning at 70 kV. A recent study has
reported that combining 70 kV with prospectively EKG-
triggered high-pitch CCTA can provide diagnostic infor-
mation with only 30 mL of contrast in patients with body
mass index <23 kg/m2, which is comparable to the
diagnostic quality with 80/100 kV using 60 mL of con-
trast.66 The study recommended the use of 80 kV for
patients with body mass index from 23 to 25 kg/m2 and
100 kV for those with body mass index >25 kg/m2.
As described in the preceding sections, application of
lower kV for CCTA has also been aided by the availability
of x-ray tubes with higher mA thresholds as well as by the
denoising capabilities of advanced IRTs, which helps offset
the increase in noise with use of lower kV.
Thoracic Oncologic Applications of DECT
Until the 1990s, pulmonary nodules were imaged with
2 kV settings, a technique that was later widely discredited.
A single-phase, postcontrast DECT can simultaneously
help assess calcification (from virtual unenhanced images)
and the degree and pattern of contrast enhancement in
pulmonary nodules. Prior studies have assessed the use of
dual-phase DECT for characterization of pulmonary

A B C

FIGURE 6. A 79-year-old man underwent DECT of the chest for evaluation of pulmonary embolism. Lung window image (A) dem-
onstrates 2 subpleural opacities in the left posterior costophrenic recess. The medial opacity (arrow) demonstrates no contrast
enhancement in the mediastinal window (B) with lack of iodine enhancement on the pulmonary blood volume image (C), which is
larger than the size of the medial opacity—features compatible with pulmonary infarct given the presence of occlusive left lower lobe
segmental pulmonary embolism. The lateral opacity (star) shows contrast enhancement (B) and increased iodine uptake (C) consistent
with focus of atelectasis.

96 | www.thoracicimaging.com Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
J Thorac Imaging  Volume 32, Number 2, March 2017
A B
FIGURE 7. A 58-year-old woman with compromised renal function (estimated glomerular filtrate rate of 28 mg/mL) underwent dual-
energy CT pulmonary angiography on a dual-source 128-section multidetector CT (Siemens Definition Flash) using 15 mL of intra-
venous contrast (Iopamidol, 370 mg%). Transverse images (A and B) demonstrated optimum contrast enhancement in the pulmonary
arteries and cardiac chambers. Note the small nonocclusive filling defects (arrows) in bilateral lower lobe pulmonary arteries suggestive
of pulmonary embolism.
nodules.67 These studies have reported that the malignant
nodules retain more contrast on delayed DECT images
acquired at 180 s delayed DECT as compared with benign
nodules, which demonstrate early contrast washout.
Kawai and colleagues have also reported the useful-
ness of DECT in a small study of 24 patients with ground-
glass opacities. The authors found contrast enhancement in
22 adenocarcinomas on iodine map images but not in
patients with pulmonary hemorrhage or inflammatory
masses.68 Although encouraging, larger multicenter trials
are needed to establish the veracity of these findings for
characterization of ground-glass opacities. Initial studies
have also shown potential for dual-phase DECT for dif-
ferentiating benign from malignant mediastinal masses.69
The iodine concentration on both early-phase and delayed-
phase postcontrast DECT was higher in malignant masses
as compared with that in nonmalignant masses in the
mediastinum. Both studies had a small sample size, neces-
sitating the need for larger-sample–sized, multicenter CT
studies to confirm these findings.
DECT can help in primary staging of tumors, in
assessment of the vascularity of lesions on iodine map
images, in assessment of angiogenesis in thoracic meta-
stases, and in assessment of lung function.70,71 DECT of the
chest can also help in therapy monitoring by enabling
objective, easy, and fast parameterization of the tumor size
and contrast medium uptake in 1 step. Recent studies have
reported better delineation between lymph nodes and
thoracic vessels on low keV virtual monoenergetic images.72
Thoracic Vascular Applications of DECT
MDCT pulmonary angiography has limited ability in
detecting small segmental and subsegmental emboli. Virtual
monochromatic images at lower keV (< 40 to 60) increase
the image contrast and enable analysis of peripheral
pulmonary arteries and more confident evaluation of sub-
segmental pulmonary embolism.73,74 Recent studies have
demonstrated the utility of virtual monochromatic images at
40 keV for evaluation of subpleural arteriole enhancement.73
Applying DECT angiography (DE-CTA) for the
evaluation of perfusion defects in cases of pulmonary
embolism can make it possible to replace nuclear medicine–
based ventilation and perfusion scanning. DECT iodine
map demonstrates the distribution of pulmonary perfusion,
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Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
Recent Advances in CT Technology
whereas xenon ventilation CT can be used to generate a
ventilation map.75,76 Even without the ventilation CT with
xenon, DECT can provide useful information on pulmo-
nary parenchymal enhancement, which helps identify per-
fusion defects and pulmonary infarcts.73,77 The iodine
images are necessary to exclude unrelated defects in
pulmonary embolism, including artifacts, pulmonary
sequestrations, and parenchymal diseases such as emphy-
sema or cysts (Fig. 6).73,78
The combination of iodine-density images with CTPA
can have 100% positive and negative predictive values in
diagnosing pulmonary embolism. A normal iodine map can
rule out a pulmonary embolism with high negative pre-
dictive value.73,79 In addition, recent studies have demon-
strated that contrast volume can be substantially reduced
for evaluation of CT pulmonary embolism using the DE-
CTA technique (Fig. 7).80
Virtual noncontrast images obtained from DECT
can help in the detection of intramural hematoma in aortic
dissection as well as in the monitoring of aortic endo-
grafts.73
Recent studies suggest the feasibility of single-phase
DECT angiography to detect endoleaks.81 Detecting aortic
endoleaks can be improved with increase conspicuity of
iodine with iodine images and low keV monochromatic
images.82 Subsequently, in patients who underwent post-
endovascular aneurysm repair and might need lifelong
follow-up examination, the total amount of radiation dose
can be reduced with single-phase DECT angiography.83
CURRENT LIMITATIONS AND FUTURE
INNOVATIONS
Despite several technologic advantages, there still
remains a rather large room for improvements in current
state-of-the-art MDCT scanners. From the standpoint of
spatial resolution, the ability to resolve smaller airways and
interstitial pulmonary structures remains elusive and would
require at least 2- to 4-fold improvement in current resolution.
Improvements in spatial resolution will also help CCTA to
better quantify luminal stenosis and tackle at least a part of
the calcified and stent-related blooming artifacts that neg-
atively affect the interpretation of the coronary arteries and
their luminal patency. The ability to visualize smaller
www.thoracicimaging.com | 97
Tabari et al
coronary arteries and collateral circulation will also benefit
from such improvements in MDCT capabilities.
Coronary calcium still remains a major limitation in
CCTA. Calcium in coronary plaques creates a “blooming”
artifact, which produces a falsely enlarged appearance of the
plaque from partial-volume averaging effects, thereby over-
estimating the severity of stenosis and leading to potential
false-positive results. Blooming artifacts from heavily calcified
plaques degrade the accuracy of CCTA to the point that
measurement of luminal stenosis often becomes impossible.
A number of studies have specifically addressed the
problem of calcium artifacts on CCTA, with limited success.
Shmilovich et al84 have evaluated the effect of modifying
window settings on reduction of blooming artifacts and on
stenosis quantification in heavily calcified coronaries. The
authors reported that wider window widths help in identifying
<50% diameter stenosis and in greater quantitative agree-
ment in stenosis severity between CCTA and QCA. Boll
et al85 showed improved calcified plaque volume quantifica-
tion using dual-energy MDCT with image postprocessing
techniques that allow for reduction of image noise and
enhancement of image contrast without implementation of
complex filter algorithms for dedicated reduction of tissue
blooming and beam-hardening phenomena. Sarwar et al86
reported significant reduction in blooming artifact with higher
resolution and smaller pixel size of thin-section flat-panel-
volume CT on 3 ex vivo hearts against histopathologic find-
ings as the gold standard. A separate study of 304 coronary
artery segments failed to show improvement in stenosis
quantification with variations in reconstruction slice thick-
ness.87 Fuchs et al88 studied the feasibility of coronary calcium
and stent image subtraction with evaluation of conventional
CCTA and subtracted CCTA (subtraction of noncontrast
images from CCTA images). Using invasive coronary angio-
gram as reference, subtracted CCTA improved the reader
confidence in 66% of calcified coronary segments as com-
pared with conventional CCTA images.
Tissue characterization is another area in which CT
has traditionally trailed magnetic resonance imaging.
Although DECT has enabled modest tissue character-
ization, there is very little evidence to support its wide-
spread use for this purpose. With validation of low-dose CT
for lung cancer screening and the prospect of identifying
incidental false-positive findings, there is a rather urgent
need for the test to differentiate meaningful incidental
findings worthy of follow-up or diagnostic intervention
from innocent bystander and harmless findings. Advances
in tissue characterization for coronary plaque character-
ization with CCTA can help in identifying the vulnerable
plaque that can precipitate a coronary event.
Contemporary limitations of MDCT are incentives for
exciting improvements in the future. Technologic advances in
MDCT have outpaced other modalities in the last decade and
a half, and it is expected that future photon-counting detector
CT scanners may be the next big technological advance with
notable impact on cardiothoracic imaging. Some vendors
have reported encouraging preclinical results from evaluation
of photon-counting detector CT scanners, which are expected
to usher in a new area of nanoparticle-based contrast agents
and substantial decrease in radiation dose.89 Although initial
prospects are encouraging for plaque characterization in car-
diovascular applications, additional technologic breakthrough
is needed to enable use in live human subjects and reduce
considerable cost creep associated with use of these highly
sophisticated detector systems.
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J Thorac Imaging  Volume 32, Number 2, March 2017
CONCLUSIONS
Recent technologic advances in MDCT have led to
notable improvements in both cardiac and thoracic appli-
cations of CT. From availability of faster and more pow-
erful MDCT scanners to DECT technologies, these
advances have enabled a host of potential improvements
in cardiothoracic applications of CT, spanning from
improved diagnostic quality, reduced contrast volume, to
reduced radiation dose.
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