lecture vienna september 16 2005
TRANSCRIPT
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Noninvasive MDCT- based Imaging of the Coronary
Arteries
Udo Hoffmann, MDDirector of Cardiac CT Research
Assistant Professor of Radiology, Harvard Medical School
Massachusetts General Hospital Boston, MA
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Challenge of Coronary Artery Imaging
Small Vessels with Complex Anatomyin Rapid Motion
Cornerstone Invasive Selective Coronary Angiography
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Prerequisites for Prerequisites for Successful Cardiac CT ISuccessful Cardiac CT I
• Temporal Resolution• Spatial Resolution• Volume Coverage
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• 330- 400 ms gantry rotation (165- 200 ms) temporal resolution (half scan reconstruction)• 0.4 x 0.4 x 0.6 - 0.75 resolution• single breath hold 8 - 14 sec• 40 - 80 ml of contrast agent (4-5 ml/s)• 500 - 950 mAs tube current (modulation)• 7 – 24 mSv
64 Slice MDCT64 Slice MDCT Protocol Protocol for Coronary for Coronary AngiographyAngiography
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Prerequisites for Prerequisites for Successful Cardiac CT IISuccessful Cardiac CT II• Appropriate Breath Hold
exact instructions (mid inspiration)exercise and observe heart rate
• Low heart rate, NSR (<65 bpm)
Beta Blocker PO/IV
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Retrospective ECG gating
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Axial Source Images
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Thin MIP 3D VRT Curved MPR
Post Processing
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P A C S
Comprehensive Cardiac CT Examination
betablocker i.v., sublingual Nitroglycerine betablocker i.v., sublingual Nitroglycerine
O F F L I N E
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Detection of significant coronary artery stenosis
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Systematic Review on Diagnostic Accuracy of CT-
based Detection of significant Detection of significant CADCAD
• 30 studies • 1849 patients• 12913 coronary segments
•13 EBCT - 847 patients•10 - 4/8 MDCT - 588 patients•7 - 16 MDCT - 414 patients
Hoffmann et al, JAMA 2005 submitted
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Diagnostic Accuracy of EBCT, 4 - and 16 - slice MDCT
Assessable
SegmentsPooled
Sensitivity
97.5% CI
Pooled Specific
ity97.5% CI
All CT 83% 80.6%-85.3% 94% 93.2%-94.6%
EBCT 83% 79.5%-87.0% 90% 89.0%-91.8%
MSCT 83% 79.8%-85.7% 96% 95.1%-96.5%
4- and 8-slice 82% 78.3%-85.2% 96% 95.0%-
96.6%
16-slice 86% 80.3%-91.4% 96% 94.4%-97.1%
All Segments
All CT 72% 69.5%-74.3% 84%83.3%-84.9%
EBCT 71% 67.0%-75.2% 77%75.0%-78.2%
MSCT 72% 71.4%-73.2% 88%87.9%-88.7%
4- and 8-slice 62% 60.9%-63.6% 84%
83.3%-84.6%
16-slice 84% 83.1%-85.1% 94%93.6%-94.9%
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RCA StenosisRCA Stenosis
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n Sens. Spec. n.e.
Ropers ACC 2005 84 91% 93% 7%Leschka Eur Heart J 2005 67 94% 97% --Raff JACC 2005 70 86% 95% 12%
Diagnostic Accuracy of 64- slice MDCT
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Maximum Intensity Projection RCA 3D VRT LCX and RCA
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Occlusion 1st diagonal branch
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Multiplanar Reconstruction
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Limitations
TECHNICAL-- Calcium- Motion - Heart Rate
CONCEPTUAL- Contrast, X-ray- Sinus rhythm- No intervention
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- decrease number of purely diagnostic invasive selective coronary angiograms- complimentary to stress testing- improve early triage of patients with acute chest pain
Potential Clinical Applications
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Study Designearly risk stratification in the ED
decision to admit to hospital
MDCT
standard clinical care (blinded to MDCT)
discharge diagnosis
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Test Raw Data
Overall
Sensitivity 5/5 1 (0.49, 1)Specificity 26/35 0.74 (0.57,0.88)Accuracy 31/40 0.78 (0.62, 0.89)PPV 5/14 0.38 (0.13, 0.65)NPV 26/26 1 (0.87, 1)DOR 286
Overall Diagnostic Accuracy of MDCT (>50% stenosis) vs. ACS
outcome
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Patient without ACSPatient without ACS
43 year old female, 3 hours of substernal chest pain radiating to the back, negative initial Troponin and CK-MB, ECG: sinus bradycardia
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• Patient with crushing chest pain• now relieved (Nitro)• Borderline ST- Elevation• No biomarker elevation
Patient with ACSPatient with ACS
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LAD Occlusion
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LCX Anomaly and Stenosis
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Perfusion Defect
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Potential Impact on Decision Making
Pretest Probability
Posttest Probability
P-value
ACSACS 0.44±0.39 0.79±0.28 0.03No No ACSACS
0.28±0.21 0.05±0.07 0.0001
Decrease average LOS in patients without ACS by 22 hours per patient
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- decrease number of purely diagnostic invasive selective coronary angiograms- complimentary to stress testing- improve early triage of patients with acute chest pain- detect coronary anomalies
Potential Clinical Applications
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Anomalous Right Coronary Artery
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- decrease number of purely diagnostic invasive selective coronary angiograms- complimentary to stress testing- improve early triage of patients with acute chest pain- detect coronary anomalies- determine bypass patency
Potential Clinical Applications
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• High sensitivity and specificity for arterial conduits and venous grafts• Limitations: distal Anastomosis in small vessels, metallic clips
Martuscelli Circulation 2004
Bypass Graft Patency
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- decrease number of purely diagnostic invasive selective coronary angiograms- complimentary to stress testing- improve early triage of patients with acute chest pain- detect coronary anomalies- determine bypass patency- improve risk predicition/ change definition of CAD
Potential Clinical Applications
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MPR of LAD in Cross SectionThin MIP
Detection of Plaque
Sensitivity 82%, Specificity 88% Achenbach et al. Circulation 2004
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r = 0.64, p < 0.001
Moselewski et al. AJC 2004
Plaque Area
Potential to detect and quantify coronary plaque
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Plaque Composition
Potential to discriminate calcified and non- calcified plaque
Leber et al JACC 2004
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SummarySummary
• Cardiac CT is a fast robust and highly reproducible noninvasive test
• Lots of promise that it may change and improve management of patients with suspected or known CAD But no data available yet
• Direct information on the presence and extent of CAD (stenosis and plaque), LV function and perfusion
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MGH Cardiac CTA 2005MGH Cardiac CTA 20051. Core Lab for US Multi-center Trial on the Detection
of Coronary Artery Stenosis with >1000 Patients2. Cardiac CT for early triage in Patients with Acute
Chest Pain 3. Core Lab for Siemens Multi-center Trial IVUS vs.
MDCT4. Non-Calcified Plaque (FHS) in Patients with Family
History of premature CAD (Framingham) 5. Correction of Image Degradation in cardiac CT
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Thank you
Thank you