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.

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

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

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

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

Clinical Evaluation of Coronary CTA

Multi-Center Trial: 16-Slice MDCT Garcia, M. J. et al. JAMA 2006;296:403-411.

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 2007 (GE) 229 patients at 16 institutions Sensitivity 93% Specificity 82%

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

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

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

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

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

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

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

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

Stents

Grafts

Grafts

Grafts

Grafts

Malagutti et al. Eur Heart J 2006 epub Grafts Vessels Segments Sens Spec Grafts 109 182 99% 96% Run-off 109 123 89% 93% Non-BP 116 288 97% 86% Malagutti et al. Eur Heart J 2006 epub

Radiation Dose: High Einstein et al, JAMA. 2007;298:317-323.

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

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

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

Angiographic vs. Functional Stenosis Meijboom et al, J Am Coll Cardiol, 2008; 52:636-643

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

Plaque Characterization Leber et al, J Am Coll Cardiol, 2005; 46:147-154

Anomalous Coronary Arteries http://bhavin.typepad.com/cardiac_images/

Anomalous Coronary Arteries http://bhavin.typepad.com/cardiac_images/

Ventricular Function

Ventricular Function

Ventricular Function: Compared to CMR Segung et al, Circulation 2006;114:654-661; 31 patients

Ventricular Function: Compared to CMR Segung et al, Circulation 2006;114:654-661; 31 patients, radial method

Valvular Function http://bhavin.typepad.com/cardiac_images/

Valvular Function http://bhavin.typepad.com/cardiac_images/

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

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

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;244:745-754

Valvular Function

Valvular Dehiscence

Valvular Dehiscence

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

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

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

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

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.

Axial Stack

Axial Slice

MIP

Volume Rendered Image

cMPR with SAX and VA

cMPR with SAX and VA, Orthogonal

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

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