1. Coronary MDCTA Applications
Thomas H. Hauser
MD, MMSc, MPH, FACC
Director of Nuclear Cardiology
Beth Israel Deaconess Medical Center
Assistant Professor of Medicine
Harvard Medical School
Boston, MA
Good afternoon. I thank the organizers and sponsors of this meeting for kindly inviting me to give this presentation.

2. Outline Possible indications for coronary MDCTA
How to approach a coronary MDCTA study

3. Outline Possible indications for coronary MDCTA
How to approach a coronary MDCTA study

4. Possible Indications for Cardiac CT
Coronary artery
CAD/Plaque
Stents
Grafts
Anomalous coronaries
Ventricular size and function
Valve imaging
Myocardial perfusion
Infarct imaging
Cardiac vein imaging
Congenital heart disease
Cardiac masses
Cardiomyopathy
Pulmonary vein imaging

5. Accuracy investigators, RSNA 2007
Detection of CAD
Accuracy investigators, RSNA 2007

6. Clinical Evaluation of Coronary CTA

7. Multi-Center Trial: 16-Slice MDCT
Garcia, M. J. et al. JAMA 2006;296:

8. Multi-Center Trials: CORE-64, Accuracy
CORE-64 reported at AHA 2007 (Toshiba)
291 patients at 9 institutions
Sensitivity 85%
Specificity 90%
Excluded patients with calcium score >600
ACCURACY reported at RSNA (GE)
229 patients at 16 institutions
Sensitivity 93%
Specificity 82%

9. J Am Coll Cardiol Budoff et al. online only
ACCURACY Trial
J Am Coll Cardiol Budoff et al. online only

10. Limitations of Coronary CTA
Coronary Motion
Slab artifacts
Ventricular Ectopy
Ventilatory Motion
Calcium
Stents
Radiation Dose

11. Hoffmann et al, J Nucl Med 2006; 47:797–806
Coronary Motion
Hoffmann et al, J Nucl Med 2006; 47:797–806

12. Higher Heart Rate = More Motion
Hoffmann, M. H. K. et al. Radiology 2005;234:86-97

13. Hoffmann et al, J Nucl Med 2006; 47:797–806
Slab Artifact
Hoffmann et al, J Nucl Med 2006; 47:797–806

14. Hoffmann et al, J Nucl Med 2006; 47:797–806
Calcium
Hoffmann et al, J Nucl Med 2006; 47:797–806

15. Raff et al, J Am Coll Cardiol 2005;46:552–7
Calcium
Raff et al, J Am Coll Cardiol 2005;46:552–7

16. Gaspar, T. et al. J Am Coll Cardiol 2005;46:1573-1579
Stents
Gaspar, T. et al. J Am Coll Cardiol 2005;46:

17. Stents

18. Grafts

19. Grafts

20. Grafts

21. Grafts

22. Malagutti et al. Eur Heart J 2006 epub
Grafts
Vessels Segments Sens Spec
Grafts % 96%
Run-off % 93%
Non-BP % 86%
Malagutti et al. Eur Heart J 2006 epub

23. Radiation Dose: High
Einstein et al, JAMA. 2007;298:

24. J Am Coll Cardiol Maruyama et al. 52 (18): 1450
Radiation Dose
J Am Coll Cardiol Maruyama et al. 52 (18): 1450

25. J Am Coll Cardiol Maruyama et al. 52 (18): 1450
Radiation Dose
J Am Coll Cardiol Maruyama et al. 52 (18): 1450

26. Problems Correlating with Angiography
Angiographic stenosis is not perfectly correlated with functional significance
Potential advantages for combining with functional imaging
Identification of non-obstructive plaque may identify patients at increased risk for adverse events
Ongoing prospective studies of prognosis

27. Angiographic vs. Functional Stenosis
Meijboom et al, J Am Coll Cardiol, 2008; 52:

28. Ostrom et al, J Am Coll Cardiol, 2008; 52:1335-1343
Outcomes after CTA
Ostrom et al, J Am Coll Cardiol, 2008; 52:

29. Plaque Characterization
Leber et al, J Am Coll Cardiol, 2005; 46:

30. Anomalous Coronary Arteries

31. Anomalous Coronary Arteries

32. Ventricular Function

33. Ventricular Function

34. Ventricular Function: Compared to CMR
Segung et al, Circulation 2006;114: ; 31 patients

35. Ventricular Function: Compared to CMR
Segung et al, Circulation 2006;114: ; 31 patients, radial method

36. Valvular Function

37. Valvular Function

38. Pouleur et al, Radiology 2007;244:745-754
Aortic Stenosis
Pouleur et al, Radiology 2007;244:

39. Pouleur et al, Radiology 2007;244:745-754
Aortic Stenosis
Pouleur et al, Radiology 2007;244:

40. Pouleur et al, Radiology 2007;244:745-754
Aortic Stenosis
Agreement between multidetector CT and TTE in the detection of normal (AVA 2 cm2), mildly stenotic (AVA 1.2 cm2 and < 2.0 cm2), moderately stenotic (AVA 0.8 cm2 and < 1.2 cm2), or severely stenotic (AVA < 0.8 cm2) aortic valve opening was excellent ( = 0.88, P < .001)
Pouleur et al, Radiology 2007;244:

41. Valvular Function

42. Valvular Dehiscence

43. Valvular Dehiscence

44. Perfusion and Late Enhancement
Nieman et al. Radiology.2008; 247: 49-56

45. Perfusion and Late Enhancement
Nieman et al. Radiology.2008; 247: 49-56

46. Perfusion and Late Enhancement
Nieman et al. Radiology.2008; 247: 49-56

47. Cardiac CT Possible indications for coronary MDCTA
How to approach a coronary MDCTA study

48. How to Review a Coronary CTA Study
Review the axial images
Interrogate multiple reconstructions at different points in the cardiac cycle to determine which has the least amount of artifact
If any abnormalities, further investigate them with MIPs MPRs, and curved MPRs.
Volume rendered images can be helpful to communicate your findings
Generally not diagnostic
Especially helpful in graft cases
The entire dataset beyond the heart needs to be reviewed to ensure that there are no other significant findings.

49. Axial Stack

50. Axial Slice

51. MIP

52. Volume Rendered Image

53. cMPR with SAX and VA

54. cMPR with SAX and VA, Orthogonal

55. Importance of Interactive Reconstructions
Ferencik et al, Radiology: Volume 243: Number 3—June 2007

56. Outline Possible indications for coronary MDCTA
Coronary artery imaging is becoming established
Stenosis
Plaque characterization
Stents
Grafts
Ventricular function
Aortic Stenosis
How to approach a coronary MDCTA study
Axial images contain all of the primary data
Use interactive reconstructions to aid in assessing problem areas