Inhaltsverzeichnis

Vorwort

Preface

The Cardiac CT Angiography Manual was written for the purpose of making the exciting new field of cardiac computed tomography and calcium scoring simpler and more enjoyable to learn. It is intended to be a useful summary of the field of cardiac computed tomographic angiography (CTA) and calcium scoring that may aid in the training process. It is not meant to replace formal, hands-on training in this field. Difficult concepts are simplified, and figures are depicted for the purposes of clarity and understanding. The information was collected and compiled from peer-reviewed literature, lectures, and textbooks of cardiac CTA. In addition, we have tried to document the experiences and tips we have learned from the many visiting fellowships and courses we attended. Finally, we have also included information from our personal experience in performing this technique. We have attempted to be as complete as possible in documenting the sources of our information.

Cardiac CTA is a relatively new field that is constantly evolving and improving. New research and clinical experience are rapidly changing this technique. The authors believe the information in this book to be reliable and in accord with the standards accepted at the time that the document was written. However, in view of the possibility of human error or changes in the field, the authors do not warrant that the information contained herein is in every respect accurate or complete and they are not responsible for any errors or omissions, or for the results obtained from the use of such information. Readers are encouraged to confirm the information herein with other sources. For example, and in particular, readers are advised to check the product information sheet included in the package of each drug and contrast agent they plan to administer to be certain that information contained in this document is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. In addition, readers are encouraged to be familiar with the concepts of radiation safety.

Robert Pelberg
Wojciech Mazur 

Klappentext

Pelberg - Mazur

Cardiac CT Angiography Manual

Cardiac CT angiography (CTA) is a rapidly growing imaging modality that provides vital diagnostic information. Consequently, interest in training for this new modality is increasing exponentially, but few practical books are dedicated to the topic and education of cardiologists in the technique.

The primary purpose of the Cardiac CT Angiography Manual is to educate medical professionals in all relevant aspects of cardiac CTA and calcium scoring in a practical and concise manner. In addition, many concepts that make learning cardiac CTA difficult are simplified and put into context. After reading this work, the reader will be taken from novice to a level that will allow him or her to begin clinical training experiences. Cardiac CT Angiography Manual will also serve as a reference and review for those who have already completed training.

Designed for residents and fellows in cardiology and radiology, this work makes difficult-to-understand concepts easy to comprehend, with the aid of intuitive diagrams. Concepts and terminology are thoroughly defined and explained. The book also compiles an extensive amount of relevant information in one place to serve not only as a simple educational tool but also as a reference once the reader is fully trained in using cardiac CTA.

ISBN 978-1-84628-674-2

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Index

A

Aberrant right subclavian artery, 124
Acoustic shadowing, 84
Agatston score, 3
Algorithm
- for CaSc, 9, 10
- for clinical decision theory, 98
- for heart rate, 66
American College of Cardiology, recommendations of, 10
Amplatzer closure device, 117, 118
Aorta
- anatomy of, 112
- ascending, 91
- evaluation of, 111
Aortic arch
- axial plane anatomy above, 92
- axial plane anatomy at, 93
- axial plane anatomy before, 93
- interruption of, 126
Aortic valve
- bioprosthesis, 107
- vegetation, 106
Aortopulmonary anomalies, 126
Aortopulmonary window, 127
Arrhythmias
- artifacts from, 88
- CTA and, 51
Arterial tree, navigation of, 78
Arteriovenous dyssynchrony, 52
Arteriovenous pacing, 52
Artery analysis, CaSc for, 78
Artifact(s)
- from arrhythmia, 88
- attenuation, 85
- banding, 89
- beam hardening, 39, 90, 91
- misregistration, 66, 86, 87
- recognition of, 85-91
- rhythm, 89
- significance of, 85
- step, 87
- straight-line misregistration, 88
- variability, 77
- windmill, 90
Ascending aorta, axial plane anatomy of, 91
Atheroma, 88
as Hounsfield unit measurements, 39
Atherosclerosis
- assessment of, 97
- medical compliance for, 12
Atrial septal defects, location of, 117
Attenuation artifact, 85
Atypical chest pain, in emergency room, 100
Autosegmentation, vessel tree by, 74, 75
Axial data, 88
- analysis of, 81
Axial plane anatomy
- above aortic arch, 92
- at aortic arch, 93
- before aortic arch, 93
- of ascending aorta, 91
- of PA, 91
- of SVC, 91
- at thyroid gland level, 92
Azygous continuation, of inferior vena cava, 130

B

Banding artifacts, 89
Beam hardening artifacts, 90, 91
- in Hounsfield unit measurements, 39
Beats per minute (BPM), heart rate in, 63
Bioprosthetic valves, 107
Black and white reversal, 73
ß-blockers, 52, 53, 56, 61, 77
- heart rate after, 66
Blurring, 90
BMI. See Body mass index

Body mass index (BMI), CTA and, 50
Bolus-timing curve, 56
Bolus tracking method, of scan timing, 53
Bone, analysis of, 97
BPM. See Beats per minute

Branch points, pseudo-lesions and, 90
Breathing, motion problems and, 60
Bronchial tree anatomy, illustration of, 96
Bronchogenic cysts, 96
Bypass graft analysis, 77-80
- clips and, 104
- CTA for, 101-104
- LAD and, 101
- LIMA and, 101
- multiphasic analysis and, 101
- occluded bypass grafts and, 102, 103
- RIMA and, 101
- SVG and, 101
Bypass graft anastomoses, examples of, 104
Bypass graft stumps, 102, 103

C

Calcified plaque, as Hounsfield unit measurements, 39
Calcium
- assessment of, 83-85
- coronary artery disease and, 3
- density score and, 3
- in Hounsfield unit measurements, 39
Calcium area, true, 84
- voxels and, 84
Calcium rupture, 84
Calcium score (CaSc)
- algorithm for, 9, 10
- for artery analysis, 78
cardiomyopathy and, 11
cumulative survival and, 8
- introduction to, 3
- limitations of, 11
- men age percentiles, 13, 14
- MI and, 12
- odds ratio of maintaining statin Rx and, 15
- prognostic significance of, 9
- risk stratification, 16
- stabilization formula for, 11
- technique, 3
- uses for, 6
- women age percentiles, 13-14
Cardiac compression syndrome, 119
Cardiac computed tomography angiography (CTA), 3, 78
- accuracy of, 26-29
- appropriate use of, 21
- arrhythmias and, 51
- basic concepts in, 30-49
- BMI and, 50
- bypass graft analysis for, 101-104
- channels in, 30
- for chest pain, 100
- clinical decision theory and, 98
- computer screen matrix, 36-37
- of coronary stents, 104-105
- data acquisition and, 50
- data reconstruction and, 51, 57
- definitions for, 45-48
- degrading factors for, 55
- delayed hypoenhancement by, 82
- detector row and, 26
- diastolic phase and, 25
- electrophysiology applications of, 108-111

- fast contiguous coverage and, 25
- FOV for, 40-43

- gantry rotation speed and, 25

- general overview of, 25-29
- Glagov phenomenon and, 27

- high temporal resolution and, 25

- hypoenhancement by, 82

- image creation essentials for, 50

- image display of, 51, 66

- image steps for, 51

- imaging planes in, 48-49

- imaging protocol for, 56

- inappropriate use of, 23

- indications for, 19-24

- injection techniques for, 56-57

- of LIMA, 54

- lumen size and, 27

- for morbidly obese, 50

- motion problems of, 60

- multidetector, 28

- myocardial infarction and, 81

- negative predictive power of, 29

- optimal heart rate for, 61

- over-reading of, 94

- pacemaker and, 51

- patient exposure dose for, 45

- patient preparation and, 52-53

- patient selection and, 50-52

- pitch and, 41

- potential use for, 19-20

- radiation and, 44

- reporting of, 97-99

- resolution of, 34-35

- scan timing for, 53-55

- sensitivity of, 26

- slices in, 30
- soft-plaque recognition and, 27
- specificity of, 26
- success requirements for, 25-26
- systematic reading of, 76-99
- temporal resolution and, 25
- total volume of contrast for, 51
- triggering and, 41-42
- uncertain use of, 22
- variability problems with, 65-66
- windowing and, 37-39
- zoom problems with, 57-58
Cardiac cycle, imaging phases with, 64
Cardiac fistulas, 130
Cardiac function, assessment of, 83
Cardiac masses, 115
Cardiac risk, diabetes and, 9
Cardiac source, of embolism, 116
Cardiac structure, assessment of, 80-81
Cardiomyopathy, CaSc and, 11
Cardiovascular risk, vascular age and, 12
CaSc. See Calcium score Catheterization laboratory, 79
Cervical aortic arch, 125
Channels, in CTA, 30
Chest pain atypical, 100
CTA for, 100
- incidence of, 100
Chest wall
- in MIP, 103
- misregistration artifacts along, 87
Cialis, 52
Clinical decision theory, algorithm for, 98
Clips, bypass graft analysis and, 104
Coarctation, 125-126
Collateral vessels, 119-120
Collimation, of CTA, 35-36
Compliance, for atherosclerosis, 12
Computed tomography detectors, 33
- rows of, 33
Computed tomography scanner, 30-49
- setup for, 30
- single-source, 31
- dual-source, 32

- 16-slice, 32

- 64-slice, 32

- 256-slice, 32, 33
Computer screen matrix, of CTA, 36-37
Contrast
- dual injection of, 83
- in Hounsfield unit measurements, 39
- intensity curve, 54
- toxicity, 51
Convolution filters
- for noise problems, 58
- types of, 59
Coronary anatomy, v. coronary physiology, 100
Coronary anomalies, 120-123. See also specific anomalies

Coronary arteries. See also specific arteries
- abnormal finding in, 80
- analysis, 77-80
- evaluation protocol, 109
- poor imaging of, 80
- soft plaque in, 80
Coronary artery disease (CAD)
- all-cause mortality without, 7
- degrees of, 27
- diagnostic techniques for, 7
Coronary artery fistulas, 130
Coronary findings, reporting on, 97
Coronary lesion, orthogonal views of, 79
Coronary motion, graph of, 60
Coronary physiology, v. coronary anatomy, 100
Coronary stenosis, before myocardial infarction, 29
Coronary stents. See also Stents
- CTA of, 104-105
- evaluation of, 104-105
- routine imaging of, 52
Coronary tree
- analysis of, 78
- navigating, 78
Coronary venous anatomy, 111
CTA. See Cardiac computed tomography angiography

Cumulative survival, CaSc and, 8
Curved multiplanar reformatting, 66, 71
- depiction of, 72
- of LAD, 72
- limitations of, 79
- of RCA, 72
- techniques of, 79
Cypher stents, 52, 105
Cystic lymphangiomas, 97
Cystic tumors, 97
Cysts
- bronchogenic, 96
- mediastinal, 96
- neurenteric, 96
- pericardial, 96
- pleuropericardial, 96

D

Dark focal area, of stents, 105
DAS. See Data assembly system
Data acquisition, CTA and, 50
Data assembly system (DAS), 31
Data reconstruction
- CTA and, 51, 57
- problems with, 57
Degenerative joint disease, 97
Delayed hypoenhancement, by CTA, 82
Detector rows, CTA and, 26
dFOV. See Displayed field of view

Diabetes, cardiac risk and, 9
Diastolic phase, CTA and, 25
Displayed field of view (dFOV), 57
Distal coronary arteries, poor imaging of, 80
DLP. See Dose length product

Dose length product (DLP), 45
Dose modulation function, 83
Double aortic arch, 125
DSCT. See Dual-source CT scanner

Dual injection, of contrast, 83
Dual-source CT scanner (DSCT), 32, 60
Dyssynchrony, atrial and ventricular, 52

E

EBCT. See Electron beam CT

Echocardiography, 83
Ejection fraction, determination of, 83
Electrocardiogram leads, placement of, 52, 77
Electrocardiogram pulsing, graphic illustration of, 44
Electron beam CT (EBCT), 3
Electrophysiology applications, of CTA, 108-111
Esophagus, evaluation of, 94
Extramural v. intramural coronary artery course, anomaly in, 121

F

Fast contiguous coverage, CTA and, 25
Fatty infiltration, imaging of, 80
Fatty plaque, as Hounsfield unit measurements, 39
Field ofview(FOV), 95
- for CTA, 40-43
Filtering
- depiction of, 59
- slice thickening and, 59
Fleischner Society, 95
Flow intensity curves, intracardiac shunts and, 116
Four-chamber view, 80
Four-dimensional analysis, 73
FOV. See Field of view

G

Gadolinium, in Hounsfield unit measurements, 39
Gantry rotation speed, CTA and, 25
Gantry, X-ray beam emanation around, 31
Glagov phenomenon, CTA and, 27
Graft findings, reporting on, 97
Graft markers, 103
Great arteries, transposition of, 127

H

Half scan integral reconstruction, 61-62
Heart rate
- algorithm for, 66
- after ß-blockers, 66
- in BPM, 63
- graphic depiction of, 60
- for optimal CTA, 61
- reduction of, 61
- variability, 86
Heart valves, assessment of, 106-107
Hemitruncus arteriosus, 126
High temporal resolution, CTA and, 25
Hounsfield unit measurements, 30, 39, 76
- atheroma as, 39
- beam hardening artifact in, 39
- calcified plaque as, 39
- calcium in, 39
- contrast in, 39
- gadolinium in, 39
- of myocardium, 82
- soft plaque as, 39
- thrombus in, 39
- tissue in, 39
Hounsfield unit scale, 37, 38
Hounsfield unit score, 3
Hypertrophic obstructive cardiomyopathy, 118
Hypoenhancement, 82
- delayed, 82
Hypogenetic lung syndrome, 95

I

Idiopathic dilation of pulmonary artery trunk, 128
Image display, of CTA, 51, 66
Imaging planes, of CTA, 48-49
Imaging protocol, for CTA, 56
Inferior hypoperfusion, 82
Inferior vena cava, azygous continuation 130
Injection techniques, for CTA, 56-57
Injection volume, 57
Intracardiac shunts, flow intensity curves and, 116
Intracavitary view, 74
Intramural anomalous right coronary artery
- example of, 121
- unroofing procedure for, 122
Intravascular ultrasound (IVUS), 75
Intravessel view, 74
In vitro stent, 105
- CT image of, 105
Iodine flux, 51
Irregular heart rhythm
- effect of, 63
- multisegment reconstruction and, 63
IVUS. See Intravascular ultrasound

L

LAD. See Left anterior descending artery

Left anterior descending artery (LAD)
- bypass graft analysis and, 101
- curved MPR of, 72
- imaging of, 65
Left arch with aberrant right subclavian artery, 123-124
Left atrial appendage thrombus, 109
Left circumflex artery, anomaly in, 120
Left internal mammary artery (LIMA)
- bypass graft analysis and, 101
- CTA of, 54
- conduits, 102
- ostium, 102
Left main coronary artery, anomaly in, 120
Left pericardium, persistent absence of, 113
Levitra, 52
LIMA. See Left internal mammary artery

Low-dose sequential scans, 54
Lumen size, CTA and, 27
Lungs, examination of, 95
Lymphangiomas, cystic, 97

M

Maximal intensity projection (MIP), 59, 68-69, 76, 78
- chest wall in, 103
- depiction of, 68
- reconstruction format, 68
- slab thickness of, 68
- thin slab of, 69
Mayo Clinic Chest Pain Unit, 10
MDCT. See Multidetector computed tomography

Mediastinal cysts, 96
Metformin, 52
MI. See Myocardial infarction

MIP. See Maximal intensity projection

Misregistration artifacts, 66, 86
- along chest wall, 87
- depiction of, 66
- from heart rate variability, 86
Mitral valve, 106
- St. Jude mechanical, 108
Morbidly obese, CTA for, 50
Morphology, reporting on, 97
Motion problems
- breathing and, 60
- of CTA, 60
MPR. See Multiplanar reformatting

Mucomyst, 52
Multidetector computed tomography (MDCT), 3, 47
Multidetector computed tomography coronary angiography
- with 16-slice system, 28
- with 64-slice system, 28
Multiphasic analysis, 73
- bypass graft analysis and, 101
Multiphasic reconstruction, 64
Multiplanar reformatting (MPR), 66, 76, 79
- curved, 66, 71, 72, 79
- oblique, 66, 70-71
Multisegment reconstruction, 62-63
- irregular heart rhythm and, 63
Multisegment scan, 62
Myocardial bridges, 123
Myocardial infarction (MI)
- CaSc and, 12
- coronary stenosis before, 29
- diagnosis with CTA, 81
- imaging of, 82
Myocardial noncompaction, 119
Myocardium, Hounsfield unit of, 82

N

Negative predictive power, of CTA, 29
Neurenteric cysts, 96
Nitroglycerin, sublingual, 53
Noise problems
- convolution filters for, 58
- of CTA, 58-60
- scatter and, 59
- voxel and, 58
Nothing by mouth (NPO), patient preparation and, 52
NPO. See Nothing by mouth

Nuclear cardiology, 27

O

Oblique multiplanar reformatting, 66
- depiction of, 70-71
Orthogonal views, of coronary lesion, 79

P

PA. See Pulmonary artery

Pacemakers, CTA and, 51
Pacing, arteriovenous, 52
Partial anomalous venous connection, 129
Patent ductus arteriosus, 127
Patient exposure, to radiation dose, 45
Patient preparation
- CTA and, 52-53
- NPO and, 52
Patient selection, CTA and, 50-52
Peak contrast density, scan timing and, 54
Perfusion
- analysis, 81-83
- reporting on, 97
Pericardial arteries/veins, 113
Pericardial cysts, 96
Pericarditis, 113
Pericardium, analysis of, 81
Persistent absence of left pericardium, 113
Persistent left superior vena cava, 129
Pitch, CTA and, 41
Plaque rupture, 84
Pledget, 103
Pleuropericardial cysts, 96
Pseudo-lesions, 76
- branch points and, 90
Pulmonary artery (PA)
- absence/proximal interruption of, 128
- anomalies of, 128
- axial plane anatomy of, 91
- stenosis, 128
Pulmonary artery trunk, idiopathic dilation of, 128
Pulmonary embolism, 113-115, 116
- example of, 114
Pulmonary sling, 128
Pulmonary valves, 107
Pulmonary varix, 129
Pulmonary venous anatomy, drawing of, 110
Pulmonary venous anomalies, 129
Pulmonary venous return, total anomalous, 129

R

Radiation
- CTA and, 44
- dose of, 44
- energy of, 45
- patient exposure to, 45
Radiologic findings
- ancillary, 91-97
- follow-up on, 95
RCA. See Right coronary artery

Reconstructed image, holes in, 52
Reconstruction
- half scan integral, 61-62
- multisegment, 62-63
- single-plane multiplanar, 70
- three-dimensional multiplanar, 67
Reporting
- on coronary findings, 97
- of CTA, 97-99
- on graft findings, 97
- on morphology, 97
- on perfusion, 97
- on scan quality, 97
- sections to include in, 97-98
Resolution, of CTA, 34-35
Rhythm artifacts, 89
Right aortic arch, anomalies, 124-125
Right coronary artery (RCA)
- curved MPR of, 72
- graft, 102
Right internal mammary artery (RIMA), 101
- bypass graft analysis and, 101
- graft, 102
Right ventricular dysplasia, 115-116
RIMA. See Right internal mammary artery

Risk lift, 15
Rotation speeds, of gantry, 26

S

Saphenous vein graft (SVG), bypass graft
- analysis and, 101
Scanner availability, 100
Scan quality, 76-77
- reporting on, 97
Scan timing
- bolus tracking method of, 53
- for CTA, 53-55
- optimal, 55
- peak contrast density and, 54
- poorly timed example of, 55
Scarring, imaging of, 80
Scatter, noise problems and, 59
Scimitar syndrome, 95
Scout films, 56
Secundum atrial septal defect, 117
Selected field of view (sFOV), 40
Serial imaging, disease progression and, 11
sFOV. See selected field of view

Short-axis template, analysis of, 81
Shunts, 116
Siemens scanner, 30
Sieverts, 45
Simpson's rule, 83
Single chamber pacing, 52
Single photon emission CT (SPECT), 34, 35
Single-plane multiplanar reconstruction, 70
Slices, in CTA, 30
Slice thickening, filtering and, 59
Slip ring, 30
Soft plaque
- in coronary artery, 80
- evaluation of, 88
- recognition, 27
SPECT. See Single photon emission CT

Stabilization formula, for CaSc, 11
Statin Rx, ratio with calcium, 15
Stents. See also Coronary stents
- cypher, 52
- dark focal area of, 105
- velocity, 52
- in vitro, 105
Step artifacts, 87
St. Francis Heart Study, graphs of, 8
St. Jude mechanical mitral valve, 108
Straight-line misregistration artifact, 88
Sublingual nitroglycerin, 53
Superior vena cava (SVC)
- axial plane anatomy of, 91
- persistent left, 129
SVC. See Superior vena cava

SVG. See Saphenous vein graft

Systemic thoracic venous anomalies, 129

T

Temporal resolution, CTA and, 25
Tera-Recon workstation, 73, 78
Thoracic aortic anomalies, 123
Three-chamber view, analysis of, 81
Three-dimensional multiplanar reconstruction, 67
Thrombus, in Hounsfield unit measurements, 39
Thyroid gland level, axial plane anatomy at, 92
Tissue, in Hounsfield unit measurements, 39
TIVA. See Tomographic intravascular analysis

Tomographic intravascular analysis (TIVA), 75
Total anomalous pulmonary venous return, 129
Total volume of contrast, for CTA, 51
Trachea, examination of, 95
Tricuspid valves, 107
Triggering
- CTA and, 41-42
- prospective, 42
- retrospective, 41-42, 43
Triple syringe technique, 57
True calcium area, 84
Truncus arteriosus, 126
Tumors, cystic, 97

U

Unroofing procedure, for intramural anomalous coronary artery, 122

V

Variability artifacts, 77
Vascular age, cardiovascular risk and, 12
Velocity stents, 52
Venous connection, partial anomalous, 129
Ventricular function, assessment of, 83
Ventricular septal defects (VSDs), 118
Vessel tree, by autosegmentation, 74, 75
Vessel view format, 74
Viagra, 52
Virtual angioscopy, 73, 74
Volume rendering technique (VRT), 66, 67, 76
- image of, 67
- of left main coronary artery, 80
Voxels
- calcium area and, 84
- noise problems and, 58
VRT. See Volume rendering technique

VSDs. See Ventricular septal defects

W

Windmill artifact, 90
Windowing, CTA and, 37-39
Window level (WL), 38, 39
Window width (WW), 38, 39
WL. See Window level

WW. See Window width

X

X-ray beam emanation, around gantry, 31
X-ray beam production. See Computed tomography scanner

X-ray density, 30
X-ray detectors, 33-34
X-ray dose, 44

Z

Zoom problems, with CTA, 57-58

Autor

Author Biographies

Dr. Pelberg graduated from Northwestern Medical School and completed a cardiology fellowship at the University of Virginia. He is level III certified in Cardiac CTA as recognized by The Society of Cardiovascular Computed Tomography. Currently, Dr. Pelberg practices cardiology at The Ohio Heart and Vascular Center.

Dr. Mazur received his medical education at the Medical Academy in Poznan, Poland. He completed his cardiology fellowship at Baylor College of Medicine in Houston, Texas. Dr. Mazur is level III certified in Cardiac CTA as recognized by The Society of Cardiovascular Computed Tomography. Currently, Dr. Mazur practices cardiology at the Ohio Heart and Vascular Center.

Reviews

"...This book is clearly written, with figures of good quality and updated references. It admirably accomplishes its goal of serving as an educational tool and reference for cardiologists and radiologists." (E.E. Kim, Journal of Nuclear Medicine, April 2008) "...Cardiac CT Angiography Manual is a practical user-oriented handbook that is recommended for any physician starting with cardiac CT angiography. It may also serve as a reference guide for trained physicians with growing experience in this field to check any technical or clinical points." (MDCT.net News)