Computed Tomography-III

DRAD411

Cardiac CT
• A cardiac computed tomography (CT) scan is a

procedure that utilizes multiple X-ray beams from

different angles to acquire high-quality, three-

dimensional (3D) images of the heart, along with the

great vessels and surrounding structures with or

without intravenous (IV) contrast media

• Cardiac CT also can diagnose calcium scoring

 CT scan of the heart shows:

• Coronary arteries that supply the heart.

• Heart chambers, muscle and valves.

• Pulmonary veins.

• Thoracic aorta, and sometimes abdominal aorta.

• Sac around the heart (pericardium).

 Indication
• To evaluate the cause of chest pain and shortness of breath.
• To check the heart arteries for calcium or plaque buildup, narrowing or blockages.
• To assess the heart valves.
• To see if there’s a problem with your aorta, including aneurysms and dissection.
• To plan for open or minimally invasive/robotic heart surgery.
• To plan for trans catheter/percutaneous valve procedures.
• To plan for arrhythmia ablation procedures.
• To assess for complications associated with the above procedures.
• To see if the congenital (since birth) heart problem.
• To see and characterize any tumor or mass in or around the heart.
• To look at the sac around the heart, if there’s fluid or calcification there.
 Contraindications
It is not indicated in some situations:
• if the patient is having an acute myocardial infarction (heart
attack)
• Hypersensitivity to contrast media
• Pregnancy
• Irregular rhythm
• Renal insufficiency
• Hyperthyroidisms
• Inability to hold breath more than 10s
• Metallic interference eg.( pacemaker)
• severe heart failure
General anatomy of the heart
General anatomy of the heart
• Patient Preparation

• Instructions for Patients:

• Check contraindications of β-blocker and.

• Adequate oral hydration with drinking clear fluids up to 1 h before the

examination.

• Avoid solids for 4 h before the CT examination and caffeine for 12 h

before CT examination.

• Taking all usual cardiovascular medications including blood pressure

control medicine.

• Discontinuing metformin for at least 48 h before and after contrast

injection is mandatory.
• Patient Positioning:

• The patient supine, feet-first in the scanner gantry with

lifting both arms above the shoulders.

• ECG leads placement outside scan range

• Patient education such as breathing instruction and

practice.

• Heart Rate Control:

• To lower the heart rate and to make the regular rhythm

during cardiac CT, β-blockers are the first-line treatment
agent
ECG leads placement
Effect of β-blockers

• – Reduce the heart rate

• – Helpful in patients with irregular heart rates, such as

premature atrial or ventricular contractions,
supraventricular tachycardia, and atrial fibrillation

• – Prevent the heart rate variation following contrast

injection

• – Diminish the diagnostic value of left ventricular

function analysis due to negative inotropic effect
Contraindication of β-blocker:

• Allergy to β-blocker

• Sinus bradycardia (HR < 60bpm)

• Hypotension (systolic blood pressure < 100mmHg)

• Decompensated cardiac failure

• Current asthma or severe COPD dependent on β2-agonist

inhaler

• Active bronchospasm

• Second- or third-degree atrioventricular block

 Scan parameters

KV 120

mA ranges between 300 and 800 mA

Gantry rotation/speed range from 270 to 350 ms

Slice Thickness range from 0.5 to 1 mm

Pitch range from 0.2 to 0.4.

FOV 200–250 mm

Scan range 10–12 cm long: from the carina to the bottom of the heart

Increment 0.4 mm
Notes
• Automatic determination of pitch (automatic pitch

adaptation or adaptive pitch technique) is available with

dual-source CT scanners, which automatically adjust the

pitch value to the patient’s heart rate.

• In patients who underwent bypass grafts: extended upper

range to the middle of the clavicle (18–25 cm)

Anteroposterior topogram showing volume coverage (field of view)
required for dedicated coronary CTA (yellow box)
Contrast Medium Injection

• Greater intracoronary attenuation leads to higher diagnostic

accuracy in the detection of coronary artery stenosis with
MDCT.

• Higher attenuation >500 HU → significant underestimation of

stenosis in smaller vessels.

• Lower attenuation < 200 HU → poor coronary three-

dimensional image.

• The optimal vascular attenuation for stenosis detection in

coronary CTA ranges from 250 to 350 HU.
Factors Affecting Coronary Artery Enhancement:

• Patient’s body size and cardiac output.

• Concentration of contrast medium.

• Contrast volume

• – As the speed of CT data acquisition increases, smaller amount

of contrast media is required. Therefore, injection protocols
must be adjusted to reduce unnecessary contrast agent.

• With 64-slice scanners, the required contrast volume is as low

as 50–70 ml.
• Injection rates of up to 4–6 mL/s via an antecubital
vein are commonly used for coronary CTA.
Image Processing Techniques

1- Axial Review:

The initial step to check the image quality in terms of contrast

enhancement and motion artifacts.

Offers axial review for the presence and extent of calcified and

non-calcified plaque → determine the best post-processing

tools.
2- Multi-planar Reformation (MPR):

• The main planes for the evaluation of the coronary arteries.

• Suitable to understand relationship between lesion and

surrounding structure.

Limitations:

• Less useful to display the entire length of an artery.

• Allows a potential error of stenosis grading due to partial

volume averaging .
3- Maximum Intensity Projection (MIP)

• Displaying only the highest attenuation value in a given slice.

• Useful for coronary artery imaging, especially better for displaying

small-caliber segments.

Limitations:

• Coronary artery calcification can lead to overestimation of stenosis,

even in the presence of small amounts of calcium.

• – Non-calcified plaque without significant luminal narrowing will be

overlooked because of its low attenuation value

• – Limited perception of 3D relationships between structures by a lack

of depth information
4-Three-Dimensional Volume Rendering Technique (VRT)

• Quickly provides an initial overview including spatial

relationships

• Accurately defines complex anatomy of the heart and

coronary arteries

• Particularly useful in patients with coronary artery bypass

grafts

Limitation:

• Operator-dependent, poor quantitative measurement

Axial cardiac CT Multi-planar Reformation of cardiac CT
Maximum Intensity Projection Three-Dimensional Volume Rendering
Patient with normal coronary
morphology, as visualized by
64-slice MDCT.
A = aorta
LA = left atrium
LM = left main coronary
artery
LAD = left anterior
descending coronary artery
LCX = left circumflex coronary
artery
RCA = right coronary artery
RA = right atrium
RV = right ventricle
LV = left ventricle
PDA = posterior descending
coronary artery
(A) Invasive selective coronary angiography demonstrates mild luminal narrowing in
proximal LAD (arrow)
(B) MIP image across LAD plane shows large non calcified plaque causing moderate
(0%–30%) luminal obstruction in proximal LAD segment.
(C) 3-Dimensional volume-rendered CT image.
(A)3-Dimensional volume-rendered image of patient showing status after left internal
mammary graft to middle segment of left anterior descending coronary artery
(arrowheads).
(B) Curved MPR image with sharp image filter reconstruction of right coronary artery in
patient with percutaneous stent placement (arrowhead).
Cardiac CT protocols
1-Prospective ECG Triggering (Step-and Shoot or Sequential
Mode):

• Prospectively ECG-triggered technique is a low-radiation dose

scanning method using sequential mode to acquire axial images
and an incrementally moving table to cover the heart with
minimal overlap of axial slices.

• This technique in cardiac CT is not new and it recognizes that CT

image synchronization with heart diastolic phase was optimal
for heart imaging. However, the results were not being achieved
when the patient heart rate increases
• the principle of data acquisition in this technique takes place
only in the selected cardiac phase (diastolic) by selectively
turning on the X-ray tube when triggered by the ECG signal.
The X-ray tube is remained off for most of the scanning period
especially other than diastolic phase in cardiac cycle.

• during the image acquisition, the table is stationary and then

moves to the next position for another scan initiated by the
subsequent cardiac cycle (diastolic phase) this results lead to a
significant reduction in radiation dose.
Advantage of prospective ECG triggering

• Relatively lower radiation dose of 3–5 mSv.

• This technique is mainly used for quantification of coronary calcium,

but recently it is increasingly used for coronary CTA examinations.

• Longer z -axis coverage available with 256- or 320- slice scanners

ranging from 12.8 to 16 cm in one gantry rotation permits full
cardiac coverage in one gantry rotation with prospective ECG
triggering.

• The lengthening (padding) of the x-ray tube on time allows a

reconstruction in another phase, if motion artifact is problematic in
one phase.
limitation of prospective ECG triggering

• Image quality is dependent on the heart rate and heart rate

variation.

• Maximum heart rate threshold for prospective ECG

triggering is between 60 and 65 bmp of single-source CT and

< 75 bpm for dual-source CT.

• Functional information about cardiac valve motion or wall

motion is not available.

Cardiac CTA with prospective ECG triggering protocol
• 2- Retrospective ECG Gating:

• Retrospective gating is needed when cardiac function

measurements are needed. Because images are acquired
throughout the cardiac cycle, volume measurements of the right
and left ventricles can be obtained in end-systole and end-diastole,
allowing the calculation of stroke volume, ejection fraction, and
cardiac output. Retrospective gating is also helpful in patients with
irregular heart rhythm to help ensure diagnostic images of the
coronary arteries are acquired. In contrast to prospective triggering,
retrospective gating allows the user to employ ECG editing to
remove artifacts related to premature ventricular contractions or
dropped beats.
Retrospective gating, which is a spiral acquisition

where the CT tube current remains on during the

cardiac cycle.

To reduce radiation, the tube current may be

decreased during systole (electrocardiography

[ECG] tube current modulation).

Retrospective ECG-gated helical computed tomographic acquisition, with continuous
gantry rotation and simultaneous patient table translation.
Radiation dose from the scan is (A) highest with ECG-based tube current modulation
turned off,
(B) lower with the full tube current applied for a diastolic portion (eg, 40%to80%) of the
cardiac cycle,
(C) lowest with full tube current applied during only a single phase of the cardiac cycle.
. (A) Retrospective gating without tube current modulation uses full tube current
throughout the duration of the cardiac cycle.
(B) Retrospective with tube current modulation applied the full current is only
delivered during a late diastoles
(C) Prospective triggering only uses full tube current with heart diastolic phase
3- Volume CT Technique Using 256- or 320-Slice Wide Detector:

• Recent technical development of the large detector arrays is able to acquire images of the whole
heart in a single heart beat .

• 256-slice MDCT: detector configuration of 256 × 0.5 mm, 12.8 cm z -axis coverage per rotation,
and rotation time of 270 ms.

• 320-slice MDCT: detector configuration of 320 × 0.5 mm, 16 cm z -axis coverage per rotation,
and rotation time of 350 ms.

• No table movement during data acquisition is able to eliminate the stair-step artifacts.

• The lack of slice overlap leads to low radiation exposure.

• 4- Dual-Source CT (DSCT):

• As a technology for improving temporal

resolution, a dual-source CT system has been
recently introduced employed two x-ray
sources and two corresponding detectors offset
by 90–95°.
 Selection of Optimal CT Scan Protocol

• Prospective ECG-triggered techniques should be used in patients who have stable sinus rhythm and
low heart rates.

• Retrospective ECG-gated techniques may be used in patients who do not qualify for prospective
ECG-triggered scanning because of irregular heart rhythm or high heart rates or both.

• If the cardiac anatomy or coronary artery disease is the main concern, prospective ECG-triggering
technique is recommended.

• If cardiac functional information is the main concern, retrospective ECG-gating technique is

recommended with additional dose-saving technique.

• If a large detector array of 256- or 320-slice is available, prospective ECG triggering is preferred.
Calcium scoring
• Cardiac computed tomography (CT) for Calcium Scoring uses
special x-ray equipment to produce pictures of the coronary
arteries to determine if they are blocked or narrowed by the
buildup of plaque – an indicator for atherosclerosis or
coronary artery disease (CAD).

• The information obtained can help evaluate whether you are

at increased risk for heart attack.
 Calcium scoring
It is a screening study that may be recommended by a
physician for patients with risk factors for CAD but no clinical
symptoms:
The major risk factors for CAD are:
• high blood cholesterol levels
• family history of heart attacks
• diabetes
• high blood pressure
• cigarette smoking
• overweight or obese
• physical inactivity
• The extent of CAD is graded according to your calcium score:

Calcium Score Presence of CAD

0 No evidence of CAD

1-10 Minimal evidence of CAD

11-100 Mild evidence of CAD

101-400 Moderate evidence of CAD

Over 400 Extensive evidence of CAD

 Calcium score

Curved multiplanar reconstructions of the left anterior descending coronary

artery (left), left circumflex coronary artery (middle), and right coronary
artery (right) demonstrate substantial calcification with blooming artifact. for
example in the proximal right coronary artery (arrow). This patient had a calcium
score of 867.
 Artifacts
1-Cardiac Motion Artifact

• -Blurring artifact ← the motion velocity of the coronary segment of interest exceeds the temporal
resolution of the CT technique

• - Stair-step artifacts occur due to mis registration of slice registration at multiple planes in patients
with heart rate variations or arrhythmia

• Remedy

• – Rapid heart rate (>70–75 bpm): the use of β-blockers, choosing appropriate reconstruction
window for each coronary artery, and multi segment reconstruction are the solutions.

• Arrhythmia: using the ECG editing to eliminate an inappropriate segment or adding a

reconstructed data set of desired segment is helpful.
2-Respiratory Motion Artifact:

• Patient’s breathing during scanning arouses image blurring, image

gaps, image overlap (double coronary artery), and also stair-step
artifacts.

• Cannot be corrected with image data reconstruction methods.

Remedy

• Redundant breathing instruction

• Oxygen supplementation

• Use higher detector row scanners or increased anatomic coverage

Motion Artifact
3-Blooming Artifact due to Partial Volume Averaging Effect :

• Blooming artifacts occur due to high-density objects, such as

coronary artery calcium and small stents (<3mm) and can arouse
pseudostenosis or non-assessable segments in coronary CTA.

• The artifact may oversize calcified plaques on the CT image and

resulted in subsequent overestimation of luminal narrowing.

• Remedy

• Use thin section width and high spatial resolution algorithms.

• Use dual energy CT with special edge-enhancing image filters.

Blooming Artifact
4- Stair-step artifact:
Patient with multiple extra-systolic beats during image acquisition. Stair-step
artifacts (arrows) are caused by irregular rhythm and are best visualized in
coronal view..