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Journal of Cardiovascular Computed Tomography

journal homepage: www.elsevier.com/locate/jcct

Editorial

Dynamic CT perfusion imaging: Few small steps toward the implementation into the real clinical
world

A RT I CL E INF O

Keywords:
Myocardial blood flow
Myocardial ischemia
Dynamic CT perfusion

Coronary CT angiography (CCTA) is a well-established, non-in- myocardial ischemia, potentially reducing the rate of unnecessary
vasive imaging modality with excellent diagnostic accuracy in the ICA.10,11 Despite these promising results, data on dynamic CTP are still
identification of coronary atherosclerosis and detection of obstructive limited to the research environment and the transition to the clinical
coronary artery disease (CAD) when compared to invasive coronary implementation seems to proceed slowly.
angiography (ICA) as reference standard.1 Moreover, several rando- The current study by Ho and colleagues in this issue of JCCT re-
mized controlled trials have shown how the use of CCTA in the man- presents an important advance in the field of CTP imaging.12 The Au-
agement of symptomatic patients with stable CAD improves patients’ thors provide data from 115 consecutive patients referred to a clinical
outcomes, reducing the risk of long-term fatal and non-fatal myocardial CTP service, with a detailed report on test indications and downstream
infarction.2,3 According to current guidelines the decision of myocardial utilization of ICA. Of note, CCTA was used as a gatekeeper to dynamic
revascularization should be guided by the presence of myocardial CTP. In particular, patients underwent CTP only if moderate to severe
ischemia.4,5 Given the accepted mismatch between the degree of cor- disease was detected on CCTA or if the study was not diagnostic. By
onary stenosis and the extent of myocardial ischemia,6 additional contrast, patients with no or mild CAD were discharged. The decision of
functional testing is often required when CAD is detected by CCTA. In performing ICA was left to the referring cardiologist. Color-coded maps
this context, both non-invasive and invasive techniques are currently representing the distribution of MBF into the myocardium were cre-
used for the evaluation of myocardial ischemia, in order to select pa- ated. MBF was then sampled in each of the three vascular territories
tients who will benefit most from myocardial revascularization in ad- (i.e. left main/left descendent coronary artery, circumflex coronary
dition to medical therapy. artery and right coronary artery), by drawing a region of interest in
The combination of CCTA and CT perfusion imaging (CTP) offers a representative myocardial areas of visually reduced MBF. A previously
unique and comprehensive tool for the evaluation of patients with validated value of CT-derived MBF lower than 105ml/100ml/min was
stable chest pain, providing information on coronary atherosclerosis used to define myocardial ischemia13 in the current population. Pre-
and myocardial perfusion during the same session. Myocardial blood valence of myocardial ischemia by dynamic CTP was 25%. Interestingly
flow (MBF) is a direct index of myocardial perfusion and its quantifi- among these patients, 62% underwent ICA, of whom 94% were treated
cation as a function of time (i.e. using a dynamic approach) was firstly with percutaneous coronary intervention (PCI). Short-to-mid term
attempted by electron beam CT (EBCT) in the 80's.7 At that time, sev- outcomes were good; in particular 88% of patients remained free from
eral technical issues (e.g. insufficient spatial resolution and limited myocardial infarction, death or re-hospitalization over a mean period of
heart coverage) prevented the step of moving CTP from a mere research 14 ± 8 months.
environment to the clinical setting. Recent technical developments have The data presented therefore add to the existing literature on CTP
renewed the interest in dynamic CTP and growing evidence is rapidly imaging, providing preliminary real world data, even though from a
emerging. Similarly to EBCT and positron emission tomography, dy- small, single-center population. Several points are worth noting. First,
namic CTP relies on multiple sampling of the same volume of myo- the population evaluated was not the “ideal” population for CCTA, due
cardium over time, in order to acquire the data required to construct to the high-calcified burden and the high prevalence of coronary stents.
time-attenuation curves (TACs). Applying mathematical modelling to In both situations, CCTA likely fails in the evaluation of vessel lumen,
the TACs, MBF and other perfusion parameters are then calculated.8 due to a combination of blooming effect and beam hardening artefact,
Several observational studies have demonstrated good ability of CT- thus leading to a high rate of unnecessary additional testing. The choice
derived MBF in the discrimination between ischemic and remote of performing CCTA first, followed (only if required) by dynamic CTP in
myocardial territories in selected populations.9 More importantly, the the same session prevented this drawback, with 94% of the patients
addition of dynamic CTP has been shown to improve the specificity of referred to ICA undergoing also coronary revascularization. This
CCTA alone in the identification of coronary stenosis causing finding is of great value because it may have important implications for

https://doi.org/10.1016/j.jcct.2019.06.010
Received 15 May 2019; Received in revised form 2 June 2019; Accepted 10 June 2019
Editorial

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Whether one of these two techniques is superior to the other has not jcmg.2018.07.022.
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validate CT-derived MBF. Lastly, there is a wide variability in physio- on downstream testing and 12-month outcomes of a CT-myocardial perfusion ser-
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Conflicts of interest 16. Danad I, Szymonifka J, Schulman-Marcus J, Min JK. Static and dynamic assessment
of myocardial perfusion by computed tomography. Eur Heart J Cardiovasc Imaging.
2016;17(8):836–844. https://doi.org/10.1093/ehjci/jew044.
None.

Appendix A. Supplementary data Alexia Rossi∗

Department of Biomedical Sciences, Humanitas University, Pieve Emanuele,
Supplementary data to this article can be found online at https:// Milan, Italy
doi.org/10.1016/j.jcct.2019.06.010. Department of Diagnostic Imaging, Humanitas Clinical and Research
Hospital - IRCCS, Rozzano, Milan, Italy
References E-mail address: [email protected].
Fabio Fazzari
1. Miller JM, Rochitte CE, Dewey M, et al. Diagnostic performance of coronary angio- Department of Cardiovascular Medicine, Humanitas Clinical and Research
graphy by 64-row CT. N Engl J Med. 2008;359(22):2324–2336. https://doi.org/10.
1056/NEJMoa0806576.
Hospital - IRCCS, Rozzano, Milan, Italy

∗
Corresponding author. Humanitas University, Humanitas Clinical and Research Hospital, Via Rita Levi Montalcini, 4, 20090, Pieve Emanuele, MI, Italy.