CARDIAC COMPUTED

TOMOGRAPHY
dr. Hilfan Ade Putra Lubis, SpJP(K)
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 An x-ray technique that uses a computer to create cross-sectional (or

slice-like) pictures of the heart

Ionizing radiation within a

gantry rotating around the
patient in which x-rays are
detected on a detector array
and converted through
reconstruction algorithms to
images.

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Modes
Scan
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2013 ESC guidelines on the management of stable coronary artery disease
2013 ESC guidelines on the management of stable coronary artery disease
2013 ESC guidelines on the management of stable coronary artery disease
• Consensus Statement on Utilisation of Cardiac Computed Tomography 2015
• The committee has adapted the American College of Cardiology Foundation
(ACCF)
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Clinical Indications
 Detection of CAD in symptomatic patients without known heart
disease,
 CAD risk assessment in asymptomatic individuals
 CAD detection in other cardiac conditions
 Use of CT angiography after other test results
 Use after revascularization
 Evaluation of cardiac structure and function
 Evaluation of intracardiac and extracardiac structures

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 CI : pregnancy, history anaphylactic contrast reaction, clinical
instability, renal insuff

 Relative CI : Difficulty in breath hold, obesity, maintaining body

position, CI to B-blocker, high or irregular heart rates
(particularly atrial fibrillation)

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PREPARATION OF THE PATIENT AND SCANNING SEQUENCE

 Ability to receive IV contrast

material, cooperate with breathing
instructions and to hold the breath
for approximately 10 to 20 seconds

 Relative CI : high or irregular heart

rates (particularly atrial
fibrillation), morbid obesity, and
severe coronary calcium
Control HR :
(metoprolol 25 to 100 mg orally 1 hr
before scan) or IV (metoprolol 5 mg
in repeated doses)  resting HR < 65
beats/min
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BRAUNWALD TEXTBOOK OF CARDIOLOGY
 Cardiac Computed Tomography Anatomy
 Cardiac chambers, coronary vessels, great vessels, and other surrounding
cardiac and mediastinal structures can be imaged in a multiplanar fashion

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Images can be displayed in axial, coronal, and sagittal planes

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Image planes for coronary artery evaluation, can be categorized by coronary
segmentation models

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Coronary Artery Calcium Scanning

Example of coronary artery

calcium scoring in which
C
calcified foci are identified
A
within the left anterior
C
descending (orange) and left
circumflex (pink outlined in
S
blue) coronary arteries. The
c
region's area (R-Ar) and its
o
average density in Hounsfield
r
units (R-Av) are displayed and
e
used in the area-density
calcium scoring calculation

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Data from the Multi-Ethnic Study of Atherosclerosis regarding the

distribution of coronary artery calcium (CAC) scores among men relative to
age and ethnicityCoronary calcium presence and extent are dependent on
age, gender, ethnicity, and standard cardiac risk factors. Calcium scores are
higher for age and gender among whites
Major cardiovascular outcomes observed in the study in
association with higher thresholds of coronary calcium
scores
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Coronary Computed Tomography Angiography

 Coronary CTA is a non-invasive minimal risk procedure to directly

visualize the coronary arteries
 It involves administration of contrast

 It allows visualization of the coronary arteries similar to a cardiac

catheterization with additional information about the WALL of the artery
and composition of plaque (calcified or non-calcified)

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Coronary Computed Tomography Angiography

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 A randomized clinical trial: cardiac CT among patients presenting

to the emergency department with chest pain with a normal ECG
and initial cardiac biomarkers led to more rapid discharge and cost
savings compared with a conventional serial biomarker evaluation

 A majority of patients have normal CT angiograms and can be

safely discharged, whereas approximately 20% to 50% may have
some plaque identified and require further evaluation

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Different severity grades of coronary artery lesions as depicted on cardiac CT

A. Large mixed plaque without
significant stenosis in the
proximal left anterior descending
coronary artery (curved
multiplanar reformat) with
outward arterial remodeling
(arrow) as shown in the cross-
sectional image (inset). B. Large
noncalcified plaque with outward
arterial remodeling in the right
coronary artery with mild luminal
stenosis (<25%). C. Moderate
stenosis (50%) in the proximal left
circumflex coronary artery with a
mixed plaque. D. High-grade
(>70%) stenosis of the mid left
anterior descending coronary
artery with a noncalcified plaque.
E. Total occlusion of the distal left
circumflex coronary artery.
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Severity grades of coronary artery
Triple Rule- Out
 Evaluation Post
Revascularization
 Evaluation Post
Revascularization
 Difficult lesion subsets in the cath lab

CTO
 Anomalous
Coronary Artery
• Limitation CACT in post coronary stenting :
• Image artifact from stent
• Small stent difficult to evaluate (<3 mm)
• New techniques with high definition CT  may enable more accurate
detection of ISR
Scan Artifacts
It’s important  misinterpretation

• Occures in condition
• High HR (>65 beats/mnt in single source scan)
• Misaligment of axial image (motion  respiratory)
• Ectopic heart beats
• Abrupt changes in HR during scan
• High attenuating objects (metallic object, coronary calcium)  an artefact called
“beam hardening”

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BRAUNWALD TEXTBOOK OF CARDIOLOGY
 Ventricular and Valvular Morphology and Function
• Reconstruct cardiac CT data from systolic and diastolic phase 
evaluation of LV/RV EF
• Myocardial morphology after MI such as wall thinning,
calcification, fatty myocardial replacement
• Atrial morphology and volume
• Clot in LAA
• Evaluation of cardiac valves both native and prosthetic

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• Evaluation of cardiac valve
• Motion of native or prosthetic valve
• Valvular calcification and valve area in AS
• Prosthetic valve : valve malfunction, size mismatch, tissue ingrowth, valve
thrombosis
• Weakness : physiologic valve flow evaluation
• Structural characteristics of congenital heart disease and coronary
artery anomalies as alternative to cardiac MRI

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BRAUNWALD TEXTBOOK OF CARDIOLOGY
Conclusion
• MSCT is an new modality to assess coronary disease
• It has been predicted that CTCA may emerge as the diagnostic test of choice for
patients with intermediate pretest probability of disease. (JAMA vol 298, No. 3)
• It is a rapidly advancing field and we will soon be seeing it used more frequently.
The ED may be the first place used due to the ability to rapidly evaluate chest pain.
Thank You
The Providing Regional Observations to Study Predictors of Events in the Coronary Tree Study
(PROSPECT Study)
Introduction
• Approximately 1,350.000 americans annually have an ACS
• Although there is improvement in PCI and pharmacological therapies, reccurent
major adverse cardiovascular event occur in a subtansial proportion of the cases.
• Reccurent cardiac ischaemic event can be due to :
• Recurrence at the original treatment site
• The presence of untreated lession anywhere
• Progressive lession
• Most atherosclerotic plaques responsible for future ACS are angiographically
mild
• A TCFA is the most common cause of MI and death from cardiac causes
• The prospective identification of TCFA has not been achieved, in part because the
imaging tools to identify them in vivo did not exist until recently
Methods
• The PROSPECT study was conducted in 37 sites in US and Europe
• Patients with ACS were enrolled after undergoing successful and
uncomplicated PCI for the treatment of all coronary lessions believed to be
responsible for the index event and after the completion of any other planned
interventions.
• Procedures :
• Angiography
• Gray-scale IVUS
• Radiofrequency IVUS
• From the LM and proximal 6 to 8 cm of each of the major epicardial
coronary arteries
• Angiographic qualitative and quantitative measurement were obtained :
• Entire length of the coronary tree
• Each epicardial and side branch with 1, 5mm in diameter
• Offline analyses data from gray-scale and radiofrequency IVUS
• Quantitative IVUS measurement :
• Cross sectional areas of the elastic membrane
• The lumen
• The plaque and media
• Plaque burden
• Minimal lumen area
• From Radiofrequency IVUS, plaque component were identified :
• Dense calcium
• Necrotic core
• Fibrofatty tissue
• Fibrous tissue
Lesions classification :

1. Fibrotic

2. Fibrocalcific

3. Pathological intimal thickening (PIT)

4. Thick cap fibroatheroma (ThCFA)

5. VH-thin cap fibroatheroma (VH-TCFA)

(presumed high risk)
Endpoints
• Primary endpoint:
• Incidence of MACE
• MACE by angiography adjudicated as occuring at initial treated
sites (culprit lesions) or at previously untreated coronary segment
(nonculprit lesions)
Results
Adverse event
• 11 pts had complications from vessel imaging (10 dissections and 1
perforation)  3 non fatal MI
• 3,4 years : 149 major CV events in 135 pts
• In reccurent disease, site of coronary artery :
• 12,9% at originally treated culprit lesions (118 lesion in 83 pts)
• 11,6% at non culprit lesion (104 lesion in 74 pts)
• 2,7% was indeterminate (18 events in 17 pts)
Correlates of Events Related to Nonculprit Lesion

• Mean angiographic diameter stenosis of 106 nonculprit lesions subsequently

responsible for major adverse CV events was 32,3±20,6% at base line and
65,4±16,3% at follow up (p<0,001)
• At baseline :
• 32 (30,2%) were angiographically <30% stenosis (visual)
• 30 (28,3%) >50 % but <70%
• 5 (4,7%) >70%
• By IVUS
• 55 were found to have a baseline plaque burden at least 40%
 DISCUSSION

• This study used gray-scale and radiofrequency IVUS to characterize coronary

atherosclerosis before longitudinal follow up
• 1 of 5 pts with ACS which successfully treated with PCI an contemporary
medical theraphy had reccurent major adverse CV event in 3 years
• CV events :
• Rehospitalization for unstable or progressive angina (common)
• Death from cardiac cause, cardiac arrest, and MI (less common)
• Non culprit lesions led to major CV events :
• Mild on angiography assessment
• Large plaque burden (gray-scale IVUS)
• Small luminal area (gray-scale IVUS)
• TCFA (radiofrequency IVUS)
Primary Purpose of This Study
• Atheromas that caused ACS :
• Mild stenosis
• Small luminal area and/or
• Large plaque burden
• TCFA
• From 51 nonculprit lesion-related recurrent events, 26 (51%) were TCFA
• Why from other plaqur types ?
• May not have been identified because equipment limitation
• IVUS only perform at baseline (thick-cap thin-cap)
Second Purpose of This Study

• Determine prospectively and sistematically how often recurrent events

occur at the sites of nonculprit lesions as opposed to the sites of
previously treated lesions.
• From 157 recurrents event  74 (47%) were related to original
nonculprit lesions.
• Despite successful PCI for all coronary stenoses, within 3 years after
treatment 11,6% pts had unanticipated major adverse CV events
associated with untreated coronary segments
• Most of them show no evidence of severe stenosis
• IVUS cannot be used to evaluate the distal portions of the coronary
arteries
• The use of IVUS was associated with serious adverse events
• It is unclear what therapeutic approaches might be effective in mitigating
the risk associated with specific lesion features
THANK YOU
Patient Preparation
Image quality improved at low heart rates (<65 beats per minute)
1. the inspirational breath hold (-6beats/min)
2. oral ß-blocker (50—100mg oral or 5–20 mg i.v.
metoprolol)
3. combination (-11beats/min)
4. short-acting nitroglycerin (selective coronary angiography )
Supine position
Sedation
UTILIZED
GAUGE SUITABLE FOR CTA

18 OR 20
CONTRAST ADMINISTERED WITH POWER
INJECTOR
POWER INJECTOR PARAMETERS

VOLUME OF CONTRAST-ml
300-400 mg/ml

RATE ml/sec
4-6 ml/s
image acquisition
• A low-energy topogram
determination of the adequate initiation of the coronary CTA image acquisition to ensure
homogeneous contrast enhancement of the entire coronary artery tree
• Two techniques:

1. the timing bolus technique

2. the bolus tracking technique
• CT volume dataset
Low energy Topogram
 The minimal equipment requirement for state-of-the-art coronary CTA is a 16-
slice scanner. However, 40- or 64-slice MDCT scanners are recommended, as
they increasethe volume coverage and permit reduction of the scan time
and the amount of contrast agent.
Radiation exposure
• 64-slice MDCT:11~22mSv
(ECG-controlled dose modulation is 7–11mSv)
• invasive selective coronary angiography: 2.5–5mSv,
• nuclear perfusion imaging with SPECT: 15~20mSv
Image evaluation
• Multiplanar reformatted (MPR) images

For the confirmation of pathologic findings in the long and short

axes of the vessel.
• sliding thin-slab MIP (STS-MIP) images

Enhance the visualization of coronary artery stenosis in a long-

axis view of the vessel if narrowing is caused by noncalcified
atherosclerotic plaque
Artifact
• Motion Artifacts ： occur at high rates and most often in the midsegment of
the right coronary artery

Patient imaged at heart rate of 76 beats per minute.

Axial image at level of middle right coronary artery (RCA) demonstrates typical ‘‘windmill’’
appearance of motion artifact (arrowhead)
Artifact
• Misalignment and Slab Artifacts ： high heart rates, heart rate variability,
and the presence of irregular or ectopic heart beats (e.g. PVC)
Artifact
• Blooming Artifacts ： High-attenuation structures, such as calcified plaques
or stents, appear enlarged (or bloomed) because of partial volume averaging
effects and obscure the adjacent coronary lumen, the main cause of false-
positive results in coronary CTA because of overestimation of the degree
of stenosis
Beam-Hardening Artifacts
• When an x-ray beam crosses a high-density structure, such as
calcified plaque, a stent, or surgical clips, the majority of low-
energy photons are absorbed.
• Artifacts occur only in 1 direction of the scan plane.
• However,it is important to recognize and distinguish these artifacts
from noncalcified coronary atherosclerotic plaque
Respiratory Artifacts

• Respiratory artifacts produce ‘‘stair-step’’ artifacts through the entire dataset,

including nonmoving structures, such as the bones
• Training of the breath-hold commands is mandatory to avoid such artifacts
 FINDINGS AND POTENTIAL CLINICAL APPLICATIONS
• Detection of Significant Coronary Artery Stenosis
moderate sensitivity (about 80%) and excellent specificity (about 90%)
• Detection and Characterization of Coronary Atherosclerotic Plaque
1. detects calcified or mixed plaque with sensitivities and specificities above 90%.
2. the detection of noncalcified plaques, with sensitivities and specificities ranging from 60% to
85%, but has the potential to further stratify noncalcified plaque into fibrous plaque and lipid-
rich plaque
3. smaller plaques ( ＜ 0.5 mm) are not detected
Clinical Applications of CTA
• •Screening: no application
• •Diagnosis of CAD
• Intermediate likelihood of disease **
• After equivocal/discordant stress imaging **
• Coronary anomalies
• Before valvular surgery
• Nonischemic vs. ischemic cardiomyopathy
• Acute chest pain (our ED/Cards starting a pilot study soon)
• Bypass graft patency/location (images of transplanted arteries and veins are much better)
• •Risk stratification (known CAD)
• After equivocal/discordant stress imaging

• From Journal of Nuclear Medicine Vol. 47 No. 7 1107-1118

Possible use of CTA in screening symptomatic patients

Journal of Nuclear Medicine Vol. 47 No. 7 1107-1118

Potential Clinical Applications
Limitation
• Data based on single-center, multicenter trials and studies with intermediate-risk populations
are warranted
• a very specific subset of symptomatic middle-aged white men who had a high prevalence of
CAD
Other potential applications
• coronary CTA is to improve the triage and management of patients with acute chest pain.
• preoperative risk
• patency of stents placed in the left main coronary artery
• bypass patency
Comparative Costs
• Table 1. Costs Used in Analysis, 1996 U.S. Dollars*
• CT angiogram 1500
• Positron emission tomography 1500
• Single-photon emission computed tomography 475 (NUC MED SPECT)
• Stress echocardiography 265
• Planar thallium imaging 221
• Exercise electrocardiography 110
• Coronary artery bypass surgery: 1- and 2-vessel 32, 390 (average of 1- and 2-vessel procedures)
• Coronary artery bypass surgery: 3-vessel and left main 32, 824
• Myocardial infarction: single admission 7415
• Cardiac catheterization with angiography 1810
• Percutaneous transluminal coronary angioplasty 11, 685 (average of 1- and 2-vessel procedures)
4 May 1999 · Annals of Internal Medicine · Volume 130 · Number 9
Conclusion
• MSCT is an new modality to assess coronary disease. It has been predicted
that CTCA may emerge as the diagnostic test of choice for patients with
intermediate pretest probability of disease. (JAMA vol 298, No. 3)
• It is a rapidly advancing field and we will soon be seeing it used more
frequently. The ED may be the first place used due to the ability to rapidly
evaluate chest pain.
CONCLUSION
• Severe coronary calcification remains the major limiting factor in coronary
CTA.
• The high negative predictive value of 64-slice MDCT, relative to invasive
selective coronary angiography, can rule out the presence of
hemodynamically significant CAD.
• Although data on clinical utility, cost, and cost-effectiveness are not yet
available, coronary CTA may improve the management of patients with an
intermediate probability of CAD and patients with acute chest pain.
THANKS FOR YOUR ATTENTION!
Triple Rule- Out
 Evaluation Post
Revascularization
 Evaluation Post
Revascularization
 Difficult lesion subsets in the cath lab

CTO
 Anomalous
Coronary Artery
Thank You