1. Non Invasive Cardiology First Coast Heart and Vascular
Cardiac Imaging
Echo/Coronary CT/ CMR
Millee Singh DO
Non Invasive Cardiology
First Coast Heart and Vascular

2. Introduction
Heart Failure is defined as a syndrome consisting of symptoms and sign resulting from an abnormality of cardiac structure and or function
Multiple imaging modalities are currently available to aid is diagnosis, etiology and treatment of heart failure

3. Diagnosis
Echocardiogram is the first line cardiovascular imaging for diagnosis
Advantages :
Widely available
Portable
Low cost
Non invasive
Disadvantages
Poor acoustic windows
It allows us to see :
Cardiac structure (wall dimensions, volume, geometry, valvular and pericardial abnormalities)
Function analysis which includes systolic vs diastolic dysfunction

4. Diagnosis CMR is a complementary imaging modality in HF
Gold standard for LV and RV volumes, EF and in vivo tissue characterization
Limitations:
Claustrophobia
Renal failure
MRI Conditional Devices
Timing for test

5. Etiology of Heart Failure
Many modalities can assist :
Echo
CCTA
CMR
Stress testing With SPECT / PET

6. Etiology of Heart Failure
Stress testing is the traditional noninvasive approach to detecting obstructive coronary artery disease
It provides physiologic evidence of clinically significant coronary artery stenosis by demonstrating the effects of diminished coronary flow reserve through :
Symptoms
Characteristic changes on EKG
Myocardial perfusion defects on scintigraphy/ regional wall motion abnormalities on echo

7. Ischemic Etiology of HF
Nondiagnostic findings or strong clinical suspicion for Ischemic cause  need for direct anatomical assessment
Catheter-based angiography is:
Expensive
Associated with a small risk OR
Serious complications due to the invasive nature

8. CCTA
Noninvasive coronary arteriography was first described for computed tomography (CT) in 1995
Cardiac and coronary CT imaging — Coronary CT angiography (CCTA) has a relatively low technical burden for both the operator and patient
The scanning time to acquire a three-dimensional dataset of the entire heart can take as little as 5 seconds
Most CCTA procedures are currently performed with multidetector row or multislice (MDCT or MSCT) scanners
Contrast: 60 to 120 mL is injected intravenously at a rate of 2 to 5 mL/min
Moshage WE, Achenbach S, Seese B, Bachmann K, Kirchgeorg M;coronary artery stenoses: three-dimensional imaging with electrocardiographically triggered, contrast agent-enhanced, electron-beam CT.Radiology. 1995;196(3):707
Moshage WE, Achenbach S, Seese B, Bachmann K, Kirchgeorg M;coronary artery stenoses: three-dimensional imaging with electrocardiographically triggered, contrast agent-enhanced, electron-beam CT.Radiology. 1995;196(3):707

9. CCTA Limitations  poor imaging
Heart rate greater than 60 or 70 beats/min- poor temporal resolution
Irregular heart rhythm
Inability to sustain a breath hold for at least five seconds
Severe coronary calcification or the presence of coronary artery stents
Segments with a diameter <1.5 mm can usually not be assessed for stenosis (distal coronary artery segments and some side branches)
since image reconstruction artifacts related to radiodense material such as calcium or metal can obscure the coronary artery lumen
In most cases, 60 to 120 mL is injected intravenously at a rate of 2 to 5 mL/min. Thus, CCTA is contraindicated in patients with a history of allergy to iodinated contrast medium and relatively contraindicated in patients at high risk for contrast nephropathy (eg, patients with diabetes and a serum creatinine concentration above 2.0 mg/dL
Meijboom et. al ;Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol. 2008;52(25):2135

10. CCTA Contraindicated:
CCTA is contraindicated in patients with a history of allergy to iodinated contrast medium
Relatively contraindicated in diabetes and a serum creatinine concentration above 2.0 mg/dL
Meijboom et. al ;Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol. 2008;52(25):2135

11. Why CCTA?
ROMICAT study (Rule Out Myocardial Infarction using Computer Assisted Tomography)
excellent NPV for plaque or stenosis, 100% and 98% respectively
Sensitivity for a stenosis of more than 50% was only 77%
US based ACCURACY trial: Multi center:
230 (94 %) of 245 enrolled subjects
Sensitivity 95% and Specificity 83%
Specificity fell to 53% with higher calcium burden ( Calcium scores of >400)
An Agatston CACS of 1 to 99 identifies a mild amount of plaque burden, 100 to 399 is moderate, >400 is high, and >1000 is severely elevated.
Meijboom et. al ;Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol. 2008;52(25):2135

12. Why CCTA?
International CORE 64 study: 291 (72 %) of 405 enrolled patients were eligible for analysis since they had calcium scores of ≤600
Sensitivity 85% specificity 90%
CCTA has shown its ability to effectively rule out obstructive and non-obstructive CAD with an exceptionally high negative predictive value
95 to 100 %
Meijboom et. al ;Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol. 2008;52(25):2135

13. AHA Guidelines and CCTA
JACC Vol. 63, No. 4, 2014 February 4, 2014:380–406
JACC Vol. 63, No. 4, 2014 February 4, 2014:380–406

14. CCTA Before Non-coronary Cardiac Surgery
 The ability of 64-slice CCTA to exclude the need for concomitant CABG in patients undergoing cardiac surgery has been evaluated in a few single center studies
These have demonstrated high sensitivity for detecting significant coronary artery disease
70 patients referred for cardiac valve surgery
the prevalence of significant coronary artery disease
The sensitivity of CCTA was 100 % and specificity was 92%
55 relatively young patients referred for valve replacement for aortic stenosis
the prevalence of significant CAD was 20 percent %
Sensitivity 100%, Specificity 80%
Meijboomet. Al;Pre-operative computed tomography coronary angiography to detect significant coronary artery disease in patients referred for cardiac valve surgery.J Am Coll Cardiol. 2006;48(8):1658.
Gilard et. al;Accuracy of multislice computed tomography in the preoperative assessment of coronary disease in patients with aortic valve stenosis; J Am Coll Cardiol. 2006;47(10):2020
Meijboomet. Al;Pre-operative computed tomography coronary angiography to detect significant coronary artery disease in patients referred for cardiac valve surgery.J Am Coll Cardiol. 2006;48(8):1658.
Gilard et. al;Accuracy of multislice computed tomography in the preoperative assessment of coronary disease in patients with aortic valve stenosis; J Am Coll Cardiol. 2006;47(10):2020

15. CCTA Radiation
Prospective gating : 'step-and-shoot' approach has decreased radiation exposure
Scanner is turned on only during the part of the cardiac cycle when we know the heart will be still  radiation dose 
Compared with retrospective gating ( where the scanner is on throughout the cardiac cycle)
Recent study 2013 :
11,901 patients who received CCTA scans at 15 hospitals
Analyzed the data between two groups
I (July 2008-June older tech- retrospective gating)
II (July 2009-April 2011 – “Step and Shoot Protocol” )
Results:
Radiation dose decreased by 31 % between groups I & II
No difference in scan quality
The median effective radiation dose was 4.9 mSv for S & S

17. 3D Reconstruction

18. Short axis view- Level of the Aortic Valve

19. Level of the Left Atrium

20. Example of severe stenosis and calcification
Within the LAD

21. RCA

22. Cirx

23. CMR for Coronaries
Data are not sufficient to support clinical for the routine identification of coronary artery stenosis in patients with chest pain or for the screening of patients with multiple risk factors for CAD
However, the available literature supports a clinical role for CMRI in the assessment of congenital coronary anomalies and coronary artery aneurysms
Moshage WE, Achenbach S, Seese B, Bachmann K, Kirchgeorg M;coronary artery stenoses: three-dimensional imaging with electrocardiographically triggered, contrast agent-enhanced, electron-beam CT.Radiology. 1995;196(3):707

24. CCTA vs CMRI
Free breathing targeted 3D k-space gradient echo sequence with a 1.5 Tesla system
Multicenter study of 109 patients in whom 636 (84 percent) of 759 proximal and middle coronary segments could be imaged with diagnostic image quality
Multislice CCTA had significantly higher sensitivity 85% vs 72% with CMRI and specificity 95% vs 87%
Moshage WE, Achenbach S, Seese B, Bachmann K, Kirchgeorg M;coronary artery stenoses: three-dimensional imaging with electrocardiographically triggered, contrast agent-enhanced, electron-beam CT.Radiology. 1995;196(3):707

25. Non Ischemic HF Echocardiogram is still the first line choice
Valvular disease
Cardiac tumors
Pericardial disease
Congenital Heart Disease
Diastolic dysfunction
CMR /Cardiac CT can assist in further imaging and details the factors above:
Pericardial disease and cardiac tumors
Diastolic Dysfunction ( detailed morphological changes on the LA/LV hypertrophy)
Provides further tissue characterization (Arrhythmogenic RV CM)
Infiltration/fibrosis ( T1) / inflammation ( T2 )

26. CMR
eurheartj.oxfordjournals.org

27. Key Points
 CCTA and CMRI are rapidly evolving technologies for the noninvasive visualization of the native coronary arteries for ischemia and non ischemic diagosis
Current limitations are likely to be lessened with future improvements in technology
The broader applicability of CCTA and CMRI results from research centers has not generally been established
Local practice considerations, such as level of expertise, quality of the technology, and availability and quality of alternative diagnostic strategies, may influence decision- making

28. KEY POINTS
In patients with no signs or symptoms suggestive of CAD, neither CCTA nor CMRI should be used to screen for coronary disease
Noninvasive coronary angiography is reasonable for symptomatic patients who are:
Intermediate risk for CAD after initial risk stratification
ECG uninterpretable for ischemic changes (baseline ST segment abnormalities, LBBB)
Patients who are unable to exercise
Patients with equivocal stress test results
Diagnostic accuracy currently favors CCTA over CMRI for these patients

29. KEY POINTS
In patients with known or suspected congenital or acquired coronary anomalies, it is suggested to use CCTA or CMRI
CMRI is preferred in younger patients, given concerns about potential long-term effects of radiation associated with CCTA
In patients with CABG in whom it is not possible to selectively engage clinical important grafts during invasive angiography, we suggest CCTA or CMRI for evaluation of coronary artery bypass graft patency
In patients with contraindications to beta blockers or iodinated contrast, CMRI is preferred to CCTA

30. Thank You