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Chapter

Cardiac CT: How It Works


J. Jeffrey Carr

KEY POINTS
l

The first functional computed tomography (CT) scanner was introduced in 1972 by Dr.
Godfrey N. Hounsfield, for which he was awarded the Nobel Prize in Medicine and Physiology in 1979.

A CT image is composed of picture elements, or pixels, that are arranged in a matrix size of
512 rows and 512 columns.

Each pixel has a value termed a CT number or Hounsfield unit (HU) that ranges from 1000
HU to 4000 HU. The values of air and water are defined as 1000 HU and 0 HU,
respectively.

In cardiac CT, a complete three-dimensional volumetric set of image data encompassing


the entire heart at either one or multiple time points during the cardiac cycle is acquired
by one or more x-ray tubes that, along with opposing detector array(s), rapidly rotate
around the patient during the exposure.

Cardiac CT requires the synchronization of the CT image with the electrocardiogram


(ECG) using either prospective or retrospective ECG gating. In both of these methods
the ECG waveform is used to coordinate the image reconstruction with the position of
the heart in the chest.

In prospective ECG gating, sometimes referred to as cardiac triggering, the QRS complex is
used to turn the x-ray tube on for a short burst during a prespecified phase of the cardiac
cycle, typically mid to late diastole.

In retrospective ECG gating, CT scan projections and the ECG waveform are recorded
simultaneously, and after the scan is completed, scan data are aligned in time with the
ECG waveforms to provide specific images of the heart at specific times in the cardiac
cycle.

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE


l

Diagnostic image quality in cardiac CT depends on high spatial resolution (thin-slice


reconstructions with isotropic voxel size) and extremely fast temporal resolution.

Signal and image contrast must also be optimized. Signal is increased by increasing the
number x-ray photons that pass through the patient, hit the detector, and thus generate
the image.

Image noise is inversely related to patient radiation exposure in most situations, and is
determined by the number of photons and their ability to penetrate the tissue factors that
are controlled by the tube settings of peak tube voltage (measured in kilovolts) and tube
current (in milliamperes).

Preserving image quality while simultaneously reducing radiation exposure is possible using
several strategies such as prospective ECG gating (x-ray pulses on only during a limited
portion of the cardiac cycle), dynamic reductions in tube current during systole during helical scanning, or the use of filters and novel reconstruction algorithms.

Cardiac CT is a diagnostic tool that can provide both


qualitative and quantitative data of cardiac structure
and function. Cardiac CT is continuing to rapidly evolve
in terms of imaging capability and is poised to alter the
landscape of diagnosis in cardiac diseases. The objectives of this chapter are to introduce and familiarize
readers with the essential technical features of cardiac
CT and provide a foundation for the remainder of the
atlas. The technical and system features of cardiac CT
systems are complicated, and most cases are specific to
a given instrument. The reader interested in a more
in-depth treatment is directed to the sources listed in
the suggested reading list at the end of the chapter, specific manuals provided by CT system manufacturers, and
published articles targeted at specific topics. The following should serve as an introduction and foundation upon
which to build a more comprehensive knowledge of the
technical aspects important to cardiac CT.
CT was introduced to the world as a new diagnostic
tool in 1972 by Dr. Godfrey N. Hounsfield who was
working as a scientist at EMI Limited in Middlesex,
England. Earlier work by the physicist, Allan Cormack,
a professor at Tufts University, provided the theoretical
framework for CT. The impact of this innovation on
medicine is profound and resulted in the awarding of
the Nobel Prize in Medicine and Physiology in 1979
to Drs. Cormack and Hounsfield. The fundamental
advance of CTwas that a transaxial image of the internal
structures of an object could be produced from multiple
projections of the object using an external x-ray source
and detector. The original EMI scanner (Fig. 1-1) was
designed to acquire two slices of the head in 5 minutes.
Advances in early-generation CT systems quickly led to
CT systems that could image the entire body with
improved reconstruction times. In early-generation CT

systems, imaging of the lung and abdomen was compromised by respiratory motion. To minimize the artifacts,
imaging during suspended respiration was used. The
heart, with its constant motion, was effectively obscured.
In fact, the motion of the heart resulted in artifacts that
in many cases obscured detail in the surrounding lungs
and mediastinum. Even now, gross patient movement
will dramatically compromise image quality in a variety
of ways. In the 37 years since the introduction of CT,
systems have advanced to where 320 images at submillimeter spatial resolution can be acquired in less than

n Figure 1-1 The initial EMI scanner was designed to image the
brain. The patients head was placed in the gantry and surrounded by a
water bath. Two slices were obtained in 5 minutes, and the typical
examination consisted of 10 slices that could be obtained in 25
minutes of scan time. The voxel dimensions were initially 3  3  13
mm, although subsequent modifications allowed for 1.5  1.5-mm
pixels and variable slice collimation. (From Curry TS III, Dowdey JE,
Murry JRC (eds): Christensens Physics of Diagnostic Radiology, 4th ed.
Philadelphia, Lea & Febiger, 1990, with permission.)

Chapter 1

0.3 seconds. This dramatic advance in technical capability now provides a substantial capability for imaging of
the heart and coronary arteries with an image quality
not previously obtainable by any means noninvasively.
The factors determining image quality with cardiac CT
are comparable with those in other imaging applications
and consist of spatial resolution, temporal resolution,
image contrast, and noise. Imaging the heart and coronary arteries shifts the weighting of these factors in
important ways. Specifically, temporal resolution sufficient to freeze cardiac motion and spatial resolution
high enough to allow evaluation of the heart from any
obliquity are required for diagnosis. This textbook
focuses on cardiac CT techniques that will optimize
imaging protocols and result in improved interpretation
of cardiac CT examinations.
The heart and coronary arteries present several challenges to noninvasive imaging. First, the heart and coronary arteries are in constant motion. The mean velocity
of the right coronary artery has been measured as 69.5
mm/s. This rapid motion requires temporal resolution
sufficient to minimize motion unsharpness. Although
the cardiac cycle is cyclical, heart rate and myocardial
contractility vary in response to the demands of the
body. Beat-to-beat cardiac variability is a challenge for
cardiac imaging, which has played a major role in both
the development and clinical application of cardiac CT.
The essence of cardiac CT is effective compensation
for cardiac motion, and the application of these techniques is critical to optimizing study quality. Although
alternative methods have been developed, current clinical applications require the synchronization of the CT
image reconstruction with the electrocardiogram with
either prospective or retrospective ECG gating. In both
of these methods, the ECG waveform is used to coordinate the image reconstruction with the position of the
heart in the chest. In prospective ECG gating, sometimes referred to as cardiac triggering, the QRS complex
is used to turn the x-ray tube on for a short burst during
a prespecified phase of the cardiac cycle, typically mid to
late diastole. This technique has been implemented in
calcium-scoring protocols and low-dose coronary CT
angiography protocols. Retrospective ECG gating is
analogous to recording a synchronized electrocardiogram during coronary angiography injection. The CT
scan projections and ECG waveform are recorded
simultaneously. Once the scan ends, the unreconstructed
scan data are aligned in time with the ECG waveforms,
and, based on various algorithms, sections of projection
data are assembled to provide specific images of the
heart at specific times in the cardiac cycle.
The epicardial coronary arteries originate from the
sinuses of the ascending aorta and course in the epicardial space between the pericardium and myocardium,
all of which are clearly identifiable on the CT images.
The typical diameters of the coronary arteries range
from 3 mm at the origin to less than 1 mm distally.

Cardiac CT: How It Works

To detect coronary artery disease, even at the basic level


of determining the presence or absence of a 50% coronary diameter stenosis, requires submillimeter spatial
resolution. In addition, the course of the coronary
arteries within the epicardial space is complex, encompassing the entire surface anatomy of the right and left
ventricles. Furthermore, the heart is oriented obliquely
within the thorax and is not symmetrical with the midline of the human body. This orientation means that
the standard orthogonal planes: axial, sagittal, and coronal are ill-suited for cardiac or coronary evaluation
(Fig. 1-2). In coronary angiography, echocardiography,
and cardiac magnetic resonance imaging, specific imaging protocols have been developed to acquire image
slices in the appropriate planes of the heart. So, for
example, in echocardiography, the technologist learns
how to angle the transducer to produce a vertical longaxis view or two-chamber view of the heart, which is
then recorded over several cardiac cycles. Likewise with
cardiac magnetic resonance imaging, the technologist
performs a series of scout images before explicitly prescribing the slice location of a given slice in a manner
that yields a vertical long-axis view of the heart.
Cardiac CT is conceptually different. In cardiac CT,
the technologist obtains a complete three-dimensional
volumetric set of image data encompassing the entire
heart at either one or multiple time points during the
cardiac cycle. The projections used to reconstruct the
images are acquired by one or more x-ray tubes that,
along with opposing detector array(s), rapidly rotate
around the patient during the exposure (Fig. 1-3). The
individual images are often anachronistically called
slices, analogous to a slice of bread. However, cardiac
CT systems are based on what has come to be called
multidetector CT and in fact acquire a block of slices
simultaneously. As an example, a common 64-channel
cardiac multidetector CT system acquires blocks of
image data using a detector 4 cm in length along the z
axis (i.e., head to foot direction). This slab of projection
data is then reconstructed into 64 contiguous images
0.625 mm thick based on the size of the discrete elements within the detector. Going back to our bread
analogy, the scanner in essence acquires the entire loaf
of bread. The loaf is then subsequently divided into
the 64 images (or slices) that are 0.625 mm thin. At present, the longest matrix detector acquires a 16-cm loaf in
the z axis that can then be reconstructed into 320 images
(or slices) that are 0.5 mm thin. This coverage is enough
to image the entire heart in a single rotation.
Cardiac CT requires images of very high spatial resolution to resolve the pathology of the coronary arteries
and to reformat the volume data into the planes appropriate for cardiac diagnosis. Spatial resolution is commonly described as submillimeter and resulting sets of
images as near-isotropic. These terms are based on the
underlying elements that produce the CT images used
for diagnosis. The CT image is composed of picture

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

A
D

B
E

C
F
n Figure 1-2 A, Transverse (or axial) view. B, Coronal view. C, Sagittal view. D, Horizontal long-axis
view. E, Vertical long-axis view. F, Short-axis view. AC, The standard orthogonal planes centered in the
left ventricle are shown. DF, The cardiac imaging planes at the same location are shown. Note how in the
true sagittal view (C) the left ventricle chamber is more elongated or pear shaped. This is corrected by
reslicing the near-isotropic voxels of the original axial images and creating a true short-axis image
(F) angled perpendicularly to the long axis of the left ventricle.

elements, or pixels, that are arranged in a matrix size of


512 rows and 512 columns (Fig. 1-4). Each pixel has a
value termed a CT number or HU, which ranges from
1000 HU to 4000 HU. The values of air and water
are defined as 1000 HU and 0 HU, respectively.
Although numerous additional factors, including the
tube focal spot size, detector, and specific reconstruction

filter, influence the measured spatial resolution, an


instructive estimate of the underlying spatial resolution
can be obtained by dividing the reconstructed image
size, sometime called the display field of view by the
matrix size of 512. A typical cardiac CT might be reconstructed into a 25-cm or 250-mm display field of view.
Dividing 250 mm into 512 rows results in each pixel

Chapter 1

X-ray
Tube
Detector

B
n Figure 1-3 Computed tomography (CT) system before (A) and
after (B) removing the outer covering. Multidetector computed
tomography systems have extensive engineering with the high-voltage
x-ray tube, capable of 140 peak tube voltage (measured in kilovolts),
and a high-sensitivity detector and associated systems all mounted on a
rapidly rotating gantry assembly. Slip-ring technology, introduced in
the 1990s, made helical scan modes possible. Before this development,
the CT scanner would have to wind and unwind the cables with each
rotation of the gantry. Optical couplings are now used to rapidly
transfer the large amounts of data acquired during a single scan off the
rotating gantry. The basic geometry of a CT system is demonstrated
with the x-ray tube opposite a detector array. The patient is positioned
within the bore of the CT system.

measuring 0.5  0.5 mm or 0.25 mm2. If the slice thickness is 0.5 mm, this creates a volume element, or voxel,
that measures 0.5  0.5  0.5 mm and represents a volume
of tissue measuring 0.125 mm3. In this example, the X, Y,
and Z dimensions of the voxel are equivalent, resulting in
a perfect cube and what is termed an isotropic voxel.
n Figure 1-4 A portion of an image
at the level of the proximal left
anterior descending coronary artery
from a coronary calcium scan
demonstrating two calcified plaques.
The square white box, placed over the
proximal left anterior descending
coronary artery, shows the region of
the image that is derived from pixels
located in columns 308 through 318
and rows 212 through 222. The redshaded regions represent the pixels that
are greater than 130 Hounsfield units
that compose the calcified plaques in
the image. Note also how the
epicardial fat around the vessels has
negative values.

Plaque 2

Plaque 1

Cardiac CT: How It Works

Noncontrast cardiac CT for calcium scoring has


classically been performed using 2.5- to 3.0-mm slice
thickness. So the voxels in a calcium-scoring study
reconstructed into 250 mm display field of view would
be 0.5  0.5  3.0 mm and represents a volume of tissue
measuring 0.75 mm3. The voxels in this case are six
times longer in the slice or z-axis direction, resulting
in anisotropic voxels. The advantages of an isotropic or
near-isotropic data set become clear during an interactive session on an imaging postprocessing workstation
(Fig. 1-5). Near-isotropic CT data sets can be reformatted into slices at any angle or orientation without
the loss of in-plane spatial resolution. So, as demonstrated in Figure 1-3, the cardiac CT scan acquired in
the axial plane can be resliced to provide images in the
true cardiac planes, such as the short axis. Likewise, for
the coronary arteries, this means that cross sections of
the coronary arteries can be obtained from the vessel
origin at the aorta to their most distal aspect with the
appropriate software tools.
Minimizing unsharpness (or blurring) and artifacts
secondary to cardiac motion requires that the images
be obtained over a very short period of time compared
with noncardiac CT applications. This is achieved, in
part, by CT systems rotating a gantry that contains a
tube and opposing detector assembly through 360
degrees very rapidly, commonly referred to as the gantry
speed. For example, a system that could rotate the
tube from the 12-oclock position through 360 degrees
in 0.3 seconds would have a gantry speed of 0.3 seconds
per rotation, whereas another system might have a
maximum gantry speed of 0.4 seconds per rotation.
Most cardiac CT systems have the capability to vary
the speed of the gantry either explicitly or as part of
custom software designed for cardiac imaging. The time
during which an image is acquired is typically shorter
than the gantry speed. How much shorter depends
on the specific reconstruction algorithm and cardiac
scan mode used to generate the image. So, for example,
in a calcium-scoring scan protocol or a low-dose
cardiac CT angiography scan, a variant of the axial

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

B
n Figure 1-5 The effect of anisotropic versus isotropic voxel
reconstructions. A, Coronal image reconstructed from thicker slices.
B, Coronal image made from submillimeter slices. The anisotropic
voxels used to reconstruct the image in A result in irregular edges and
loss of detail throughout the image. In contrast, the image in B has
quality comparable to that of the axial source images secondary to the
near-isotropic voxels used in the reconstruction. The black arrow
indicates the closed aortic valve leaflets. The white arrows demonstrate
the tissue interface of the intravascular contrast at the aortic root and
along the endocardium of the left ventricle.

scan mode is coupled with prospective ECG gating. In


axial scan modes, the gantry is rotating but the patient
is held stationary during the image acquisition. Once a
set of images is acquired, the table advances to the next
location and the next block of images is obtained based
on the ECG trigger point. In an axial scan mode, images
can be reconstructed with slightly more than one half
rotation of projection data. The algorithms have a variety of names, including half-scan and segmented reconstructions. A reasonable estimate of the effective
temporal resolution of the half-scan reconstruction
images is one half the gantry speed. If the gantry speed
is 0.3 seconds, or 300 msec, a full-scan reconstruction

(360 degrees of projection data) would have an estimated


temporal resolution of 300 msec. Reconstructing the
same scan data into images using a half-scan or segmented reconstruction (using approximately 220
degrees of projection data) would result in each image
having an approximate temporal resolution of 150 msec
or one half the gantry speed.
CT scanners can also operate in a helical or spiral
scan mode. In this situation, the gantry rotates, but, in
addition, the patient is moved through the bore of scanner at a constant speed. The addition of ECG gating to
helical scan modes results in so-called cardiac helical
scans. These scans use complex reconstruction algorithms that assemble segments of projection data from
multiple detectors based on time points in the cardiac
cycle. Various approaches have been used that improve
the temporal resolution by as much as a factor of 4.
However, these algorithms, sometimes referred to as
multisector cardiac helical scans, require consistent
heart rates and appropriate matching of the gantry speed
to the cardiac cycle for optimal results. Artifacts and
changes in heart rate during the scan can degrade image
quality. Various approaches have been developed to minimize or compensate for heart rate variability during the
scan, including preparing the patient before the procedure by blocking beta receptors. Dual-source CT platforms use two tubes matched to two detector arrays
mounted on a single gantry. This geometry is coupled
with specific reconstruction algorithms to effectively
result in a temporal resolution of one fourth the gantry
speed and direct temporal resolution of less than 100
msec.
High spatial resolution and extremely fast temporal
resolution must be coupled with adequate signal and
image contrast. Image noise, if sufficiently high, can
result in nondiagnostic studies. The signal must be sufficiently greater than the level of noise to make the
desired diagnosis. The amount of image noise is commonly quantified as a signal-to-noise ratio. Signal is
increased by increasing the number of x-ray photons
that pass through the patient, hit the detector, and thus
generate the image. Image noise is inversely related to
patient radiation exposure (Figs. 1-6 and 1-7). The number of photons and their penetrating ability are controlled by the tube settings of peak tube voltage
(measure in kilovolts) and tube current (in milliamperes). In addition, the peak tube voltage and detector
arrays influence image contrast resolution. As the time
to acquire each image is shortened (i.e., a high temporal
resolution of 150 msec) and the size of each detector element is reduced (i.e., a length of 0.5 mm), the number of
x-ray photons per unit of time, or the photon flux, must
increase. Thus, cardiac CT systems include x-ray tubes
that can handle the energy and heat associated with relatively high milliampere values (up to 800 mA). The size
of the patient affects the number of x-ray photons that
successfully pass through the patient without scattering

Chapter 1
Noncardiac
30

18
Dose

25
14
20
15

10

10

CTDIvol (mGy)

Standard deviation (HU)

Noise

6
5
2

P = .5 @ 0.33 s

0
200
300
400
eff mA
P = .6 @ 0.33 s P = .7 @ 0.37 s P = .8 @ 0.37 s

100

n Figure 1-6 Image noise decreases as a function of effective


milliamperes or CTDIvol (volume of computed tomography dose
index) (mGy), both measures of radiation exposure. HU, Hounsfield
unit.

120 kVp
150 mA
CTDI 9.8 mGy
Image noise: 24 HU

120 kVp
360 mA
CTDI 23.5 mGy
Image noise: 16 HU

140 kVp
270 mA
CTDI 26.3 mGy
Image noise: 14 HU

n Figure 1-7 Effect of computed tomography (CT) technique on


image noise and radiation exposure. Two important factors of CT
technique are peak tube voltage, measured in kilovolts (kVp), and tube
current, measured in milliamperes (mA). These parameters are
analogous to the more familiar home incandescent light bulb controlled
by a dimmer switch. In the United States, the typical home circuit is
rated for 120 volts (V) and 15 amperes (A). The dimmer increases or
Legend continues in opposite column

Cardiac CT: How It Works

and are incident on the detector and thus contribute to


the image. The larger the patient is, the more the
photons from the incident beam will be attenuated or
scattered and thus not contribute to the signal that is
used to generate the image. Given the epidemic of obesity in the industrialized world and the established association of obesity with diabetes and cardiovascular
disease, it is critical that cardiac CT systems be capable
of imaging with acceptable quality even large, if not
obese, individuals. The amount of ionizing radiation
required to obtain sub-millimeter images of the coronary
arteries is greater than standard imaging techniques that
use thicker slices when using traditional CT approaches.
A detailed discussion of issues related to radiation
exposure and cardiac imaging was recently published
for those interested in learning more is listed in the
Suggested Readings at the end of this chapter. Several
strategies have been implemented by CT equipment
manufacturers to significantly reduce patient exposure
with cardiac CT angiography. These include the use of

decreases the current through the circuit, resulting in more or less


light (and heat) output by the filament of the bulb. X-ray tubes
respond similarly, with increasing or decreasing tube current (mA),
resulting in a greater or lesser quantity of x-ray photons and heat. The
product of the tube current (mA) and exposure time in seconds (s) is
commonly refered to as the mAs and is an estimate of the number of
x-ray photons produced in a given exposure. In cardiac CT applications,
we reduce motion unsharpness by having the shortest exposure time
possible. But as the exposure time shortens, the tube current must
increase to maintain the same number of x-rays. Increasing the
potential difference of the tube from 120 kVp to 140 kVp increases
both the energy and number of x-ray photons. Higher energy x-ray
photons are more penetrating and also have a greater biological effect.
The adjacent CT images are of a phantom and demonstrate how
changes in kVp and mA settings alter image noise and radiation
exposure. Noise can be estimated in an image by measuring the mean
attenuation of a homogeneous region of interest in the image and then
calculating the standard deviation (SD) as a measure of variability
related to the imaging process. A parameter of radiation exposure
used with CT is the volume CT dose index (or CTDlvol) in milligray
(mGy), a value reported by all current CT systems. The top and
middle images of the phantom were both obtained at 120 kVp;
however, the tube current was increased from 150 mA to 360 mA in
the middle image, an increase of 240%. The middle image is less
grainy or more homogeneous. Image noise is reduced in the middle
image (24 HU compared to 16 HU). This improved image quality is
obtained by the tube producing more x-ray photons (higher mA) and
results in greater exposure as indicated by the increase in CTDlvol
from 9.8 mGy to 23.5 mGy, a 240% increase. Radiation exposure
increases linearly with mA, when other factors are held constant. In
the bottom image, a comparable reduction in image noise is achieved
(24 HU vs. 14 HU) by increasing the energy spectrum (120 kVp to
140 kVp) and tube current (150 mA to 270 mA). The increase in mA is
only 180% of the top image, the radiation exposure is increased by
268%, from 9.8 mGy to 26.3 mGy. Note in the bottom two images the
noise and appearance of the images are comparable, but the image
obtained using the lower energy, 120 kVp, results in lower exposure
(i.e., lower CTDlvol). Imaging protocols that utilize a lower energy
spectrum, 80 kVp, 100 kVp, and 120 kVp, are an effective strategy to
lower patient dose if image quality can be maintained through
appropriately selected tube current.

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

prospective ECG gating in which the x-ray pulses on


only during a limited portion of the cardiac cycle. Dynamically lowering the tube current (i.e., milliamperes)
during systole and then increasing it during the diastole
is an approach that is implemented in multiphase cardiac
helical scan protocols. In addition, various filters and
design aspects of the detectors have been used to reduce
the exposure to ionizing radiation with current cardiac
CT systems. Additional enhancements in x-ray sources,
detectors, as well as iterative and other novel reconstruction algorithms hold significant promise for further
improvements in dose reduction.
The objective of a cardiac CT examination is to provide accurate diagnostic information to the health care
team who then uses this information to implement treatments that improve the health of patients. Optimal and
consistent image quality with cardiac CT is a prerequisite to achieving that goal. However, as in all imaging
techniques that use ionizing radiation, care must be
taken to keep patient exposure as low as reasonably possible. Cardiac CT requires a team effort that includes
patient preparation, technical performance of the scan,
appropriate post-processing of the source images, and
knowledgeable interpretation of the images. As with
any tool, cardiac CT has specific applications and situations that have been demonstrated to be most appropriate. Likewise, there are clearly indications where

alternative imaging modalities or even no imaging may


be the most appropriate diagnostic strategy for the
patient. In this initial chapter, the basics of how cardiac
CT works from a technical prospective have been
reviewed. In the subsequent chapters, clinical scenarios
will integrate and expand these technical concepts of
cardiac CT into the clinical environment.

SUGGESTED READINGS
Achenbach S, Ropers D, Holle J, et al: In-plane coronary arterial
motion velocity: Measurement with electron-beam CT, Radiology
216:457463, 2000.
Budoff MJ, Shinbane JS, editors: Cardiac CT Imaging. Diagnosis of
Cardiovascular Disease, London, 2006, Springer-Verlag.
Curry TS III, Dowdey JE, Murry JRC, editors: Christensens Physics of
Diagnostic Radiology, 3rd ed, Philadelphia, 1990, Lea & Febiger.
Gerber TC, Carr JJ, Arai AE, et al: Ionizing radiation in cardiac imaging:
A science advisory from the American Heart Association Committee
on Cardiac Imaging of the Council on Clinical Cardiology and
Committee on Cardiovascular Imaging and Intervention of the
Council on Cardiovascular Radiology and Intervention, Circulation
119:10561065, 2009.
Ohnesorge BM, Flohr TG, Becker CR, et al: Multi-slice and DualSource CT in Cardiac Imaging: Principles, Protocols, Indications, Outlook,
2nd ed, Berlin, 2007, Springer-Verlag.
Rubin GD, Rofsky NM, editors: CT and MR Angiography: Comprehensive Vascular Assessment, Philadelphia, 2009, Lippincott Williams &
Wilkins.
Schoepf UJ, editor: CT of the Heart: Principles and Applications, Totowa,
NJ, 2004, Humana Press.
The Nobel Foundation: Nobel Prize in Physiology or Medicine, 1979,
Stockholm, 1979, Karolinska Institute.

Chapter

Optimizing CT Image Quality


Wm. Guy Weigold

KEY POINTS
l

Cardiac computed tomography (CT) using full-tube current throughout the cardiac cycle
provides the most flexibility to overcome cardiac motion artifact; however, this mode is
infrequently used due to its high radiation exposure.

Radiation doses with tube-current modulation can be 35% to 40% lower and are favored in
settings of low heart rates and regular cardiac rhythms.

Scanning in the axial, prospective triggered, or step-and-shoot mode provides the potential
for the lowest effective radiation doses, but provides less flexible reconstruction options
because scan data are collected only in a small portion of the cardiac cycle (typically
diastole).

At higher heart rates, an end-systolic phase can be reconstructed to provide motion-free


images.

When scanning an obese patient with a body mass index (BMI) in the range above 35 or
40 kg/m2, the use of higher peak tube voltage and output is vital to image quality to overcome soft-tissue attenuation; however, other dose-saving methods can be used to spare
total radiation dose.

Most cardiac CT centers use oral beta-blockade (e.g., metoprolol 50100 mg PO) at least
1 hour before the scan to reduce and regularize the heart rate for optimal image quality.

Arrhythmias degrade image quality by combining image data from completely different
mechanical states of the heart and different positions of the cardiac structures within
the chest. Editing the electrocardiogram on the scanner before reconstruction can salvage
a scan, but is only possible with helical cardiac CT.

10

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Volume averaging of dense coronary calcium, so-called blooming, can be overcome by


reconstructing the data with a sharper kernel, increased image enhancement, displaying
data in a wider window, and thinner slice thickness.

Respiratory motion, which can also cause pseudo-lesions in the coronary arteries that can
be difficult to correct, can be detected by examining lung windows for streaking of the lung
vasculature and step-offs (or discontinuities) of the sternum on a sagittal plane image.

Case 1
A 70-year-old man with a history of hypertension and atypical chest discomfort was
referred for coronary CT angiography. His initial heart rate was 90 beats per minute
(bpm) with occasional premature atrial contractions. Despite administration of a
beta-blocker, his heart rate remained higher than 80. A 64-slice helical cardiac CT
scan was performed (Fig. 2-1).

n Figure 2-1 A, Curved multiplanar reformat of the left descending coronary artery in the late diastolic
(80%) phase. The mid-right coronary artery is blurred by cardiac motion artifact and is uninterpretable. To
obtain usable images of the right coronary artery, reconstruction of the data was repeated using the endsystolic phase instead. B, Curved multiplanar reformat of same vessel in the end-systolic (40%) phase.
Image quality is significantly improved, with a good contrast-to-noise ratio and minimal motion artifact.
The vessel can now be interpreted and is free of disease.

COMMENTS
This is an example of the traditional method of coronary
CT angiography in which x-rays are applied continuously at a uniform level throughout the entire scan while
electrocardiographic data are collected. Axial images are
then reconstructed in a retrospective fashion using the
electrocardiographic data to select the reconstruction

time frame. Images can be reconstructed from any window in the entire cardiac cycle. This flexibility is useful
when a high heart rate or ectopy is present and can salvage what would otherwise be an uninterpretable scan.
The price for this flexibility is increased radiation dose
(in this case, 17 millisievert [mSv]) because of the application of full-tube current throughout the cardiac cycle.

Chapter 2

Optimizing CT Image Quality

Case 2
A 56-year-old man with a history of hypertension, dyslipidemia, and diabetes was
referred for coronary CTangiography for the evaluation of episodic chest discomfort.
A 64-slice helical cardiac CT scan was performed with electrocardiography
(ECG)-based dose modulation centered in late diastole (Fig. 2-2).

B
X-ray tube ON

Helical Acquisition
Maximum tube output
(100%)

Reduced tube output

Helical Acquisition
Table
movement

Tube ON (100%)

Tube OFF (0%)

C
n Figure 2-2 A, Curved multiplanar reformat of the right coronary artery in the late diastolic (70%) phase demonstrating good image
quality with a high contrast-to-noise ratio. A small calcification is present in the proximal vessel, but there is no obstructive disease.
Examination of the remaining coronary arteries also revealed no obstructive disease. B, Curved multiplanar reformat of the right coronary
artery from the same scan, but reconstructed in the end-systolic (40%) phase at a point in the cardiac cycle at which the tube current is
markedly reduced with tube-current modulation. Image quality is now poor with increased noise. This data set is of insufficient quality to
rule out significant coronary artery disease. However, the effective radiation dose was low (7 millisievert [mSv]) because of the use of tubecurrent modulation. C, Curved multiplanar reformat of the left descending coronary artery of a different patient to demonstrate the third
method of coronary computed tomography (CT) angiography: prospective electrocardiography (ECG)-triggered axial scanning. Image quality
is comparable with that of the best helical scans, but the effective radiation dose is much lower (3.6 mSv). D, Graphic depiction of three
methods of cardiac CT. Top, Standard traditional helical CT with full tube current applied throughout the scan. Axial data sets are then
reconstructed from any cardiac phase desired. Middle, Helical CT with the application of ECG-based tube current modulation. Instead of
applying full-dose radiation throughout the scan, the tube current is fluctuated in sync with the cardiac rhythm, such that full tube current
is maintained only during a predefined phase of the cardiac cycle. Throughout the remainder of the cardiac cycle, tube current is reduced to
minimize radiation dose. Bottom, The newer, prospective ECG-triggered method of cardiac CT. In this case, x-ray is applied in bursts at a
predefined cardiac phase, and in between these acquisitions, the tube is turned completely off as the table is advanced. This results in the
lowest radiation dose currently feasible, with effective doses as low as 2 to 3 mSv.

11

12

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

COMMENTS
In this case, ECG-based dose modulation was used, targeting late diastole for data acquisition. To save radiation, the applied tube current outside of this late
diastolic window was reduced. Hence, images reconstructed from time frames outside of late diastole had
increased noise. Dose saving with this method is approximately 35% to 40%, as seen in this case, with a reduction in dose from 11 mSv to 7 mSv. The price of this

dose reduction is a limited ability to reconstruct other


phases. Although dose modulation can reduce effective
radiation dose, it should only be used when there is confidence that diagnostic images will be acquired from late
diastole. Conditions favoring the use of tube-current
modulation include low heart rates and freedom from
arrhythmias. For more dramatic dose reduction, prospective axial scanning will yield the best results, but
the same precautions apply.

Case 3
A 75-year-old man with a history of hypertension presented for coronary CT
angiography as part of an evaluation of atypical chest discomfort. His heart rate
before scanning was 85 bpm, which was reduced to 60 bpm with the administration
of a beta-blocker. Scanning was performed using the axial mode, and his average
heart rate during scanning was 63 bpm (Fig. 2-3).

n Figure 2-3 A, Double oblique slab maximum intensity projection reconstructed in 70% phase of late
diastole reveals low-density areas suggestive of plaque (arrow) and contrast column dropout suggestive of
stenosis (arrowhead). However, the contrast borders are blurred and indistinct, which suggested the
presence of motion artifact. The middle segment of the right coronary artery is particularly prone to
motion artifact. Alternate phases were reconstructed in the 75% and 80% phases. B, Reconstruction in the
80% phase of late diastole (just 95 msec later that the 70% phase) provides much better image quality, free
of motion artifact. It can now be appreciated that the vessel is disease free.

COMMENTS
Even in the setting of good heart rate control, motion
artifact may be present in some reconstruction phases.
In every case, multiple (at least three) phases should be
reconstructed and evaluated to identify the best phase
with the least amount of motion artifact. Some experts
even recommend routinely reconstructing 10 or even
20 phases in every case and evaluating each for motion
artifact.

In the setting of a high heart rate, diastasis, which


shortens with increasing heart rates, may not be long
enough to obtain motion-free acquisition data. Endsystole, however, is less variable in its duration and, in
cases like these, may provide an adequate window in
which to obtain motion-free data. If the helical scanning
mode without ECG-based dose modulation is used to
acquire data, the end-systolic phase can be reconstructed
to provide motion-free images. The penalty for this flexibility is a higher radiation dose (in this case, 18 mSv).

Chapter 2

Optimizing CT Image Quality

Case 4
Three patients presented for coronary CT angiography as part of an evaluation of
atypical chest discomfort (Fig. 2-4). Patient 1, a 45-year-old woman, was 50 200 in
height and weighed 250 lb (BMI 55). Patient 2, a 70-year-old man, was 50 700 in
height and weighed 325 lb (BMI 42). Patient 3, a 50-year-old woman, was 50 400 in
height and weighed 225 lb (BMI 40).

C
n Figure 2-4 A, Patient 1 was scanned using the helical mode with a tube voltage of 120 kV and a tube current of 300 mA (effective radiation
dose of 11 millisievert [mSv]). Despite motion-free images and good patient cooperation during scanning, image quality is poor due to excessive
noise. Image quality is insufficient for coronary evaluation, and a focal coronary obstruction cannot be excluded. Although a radiation dose of 11
mSv might be viewed as an acceptable dose for this middle-aged woman, the diagnostic value of a test using ionizing radiation was lost due to
inadequate image quality. B, Patient 2 was scanned using the spiral mode with a tube voltage of 120 kV and a tube current of 500 mA.
Good image quality is achieved in part through soft filters and thick reconstructed slice width, but primarily by maximizing x-ray tube output.
Although the images are adequate for ruling out obstructive disease, the radiation dose of 21 mSv is undesirable. This is less concerning for
this elderly man but would be unacceptable in a younger patient, especially a younger woman. C, Curved multiplanar reformat of the right
coronary artery in patient 3 scanned using the axial mode with a tube voltage of 140 kV and a tube current of 850 mA. Image quality is
comparable with that of patient 2, but the effective radiation dose is only 5.5 mSv. The significant reduction in dose is due to the use of the
electrocardiography-triggered axial scanning mode. The higher voltage ensures sufficient photon penetration of the patients large body mass.

13

14

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

COMMENTS
Obese patients present a significant challenge to optimizing cardiac CT image quality. When scanning obese
patients with a BMI in the range above 35 or 40 kg/m2,
the use of higher peak tube voltage and output is vital to
image quality to overcome soft-tissue attenuation. However, for this reason, it also becomes especially important
to use dose-saving techniques such as ECG dose modulation and axial scanning. In scanning obese patients, additional steps to ensure optimal image quality include heart
rate slowing (to avoid compounding reduced image quality from soft-tissue attenuation, with motion artifact) as

is sufficient contrast volume. Using all available options


including axial scanning, soft reconstruction filters (or kernels), thick-slice reconstruction (which reduces image
noise), attention to heart rate control with the use of
beta-blockers, and optimizing contrast opacification,
scanning these patients is still only sometimes successful.
Generally speaking, once the BMI exceeds 45 kg/m2, diagnostic image quality is difficult to achieve even in normal
studies and nearly impossible when image interpretation
is further challenged by the presence of diffuse coronary
lesions, arterial calcification, or stents.

Case 5
A 66-year-old man was referred for coronary CT angiography as a follow-up to
abnormal single-photon emission CT myocardial perfusion imaging, which
demonstrated a reversible inferior perfusion defect. His initial heart rate was 89 bpm
and regular. After receiving 15 mg metoprolol intravenously, his heart rate decreased
to 64 bpm. An axial ECG-triggered cardiac CTwas performed (Fig. 2-5). During the
scan acquisition, his heart rate increased to 80 bpm.

n Figure 2-5 A, Thick maximum intensity projection demonstrating the right coronary artery. An area of low density and decreased
contrast opacification (arrow) seems to suggest an apparent stenosis. However, because of blurring in other parts of the vessel and the
absence of a visible plaque, motion artifact was suspected. No other phases could resolve the motion artifact. After additional beta-blocker
administration, the patient was rescanned using a similar protocol (and a second dose of intravenous contrast). B, Thick maximum
intensity projection reconstruction of the right coronary artery from the second scan demonstrates that the apparent stenosis has now
resolved, confirming that it was pseudo-stenosis caused by motion artifact.

COMMENTS
This is an example of insufficient patient preparation
and the impact of heart rate and rhythm on scan quality.
The error in patient preparation in this case was most
likely inattention to the heart rate immediately

preceding scanning. Most cardiac CT scanning centers


use oral beta-blockade (e.g., metoprolol 50100 mg
PO) at least 1 hour before the scan. Despite this,
patients who appear to be adequately beta-blocked must
still be observed closely as they move from the prep
room to the scanner suite. In some patients, anxiety

Chapter 2

about the scan can cause an increase in rate just before


scanning. The technician or nurse must recognize this,
and the patient should be further medicated (using supplemental intravenous beta-blockade) to achieve truly

Optimizing CT Image Quality

15

adequate heart rate suppression. In some institutions,


low-dose anxiolytics are used to address this issue,
although this may not be feasible in all institutions or
in all patients.

Case 6
A 72-year-old woman with a history of hypertension, dyslipidemia, and smoking was
referred for evaluation of chest pain and an abnormal electrocardiogram. Occasional
premature ventricular contractions were noted during scan preparation. Her initial
heart rate was 70 bpm. She received 10 mg metoprolol IV, which reduced her heart
rate to 58 bpm. Helical cardiac CT was performed (Fig. 2-6).

PVC

PVC

PVC

n Figure 2-6 A, Axial images at three slice levels and coronal


reformat demonstrate poor image quality. The heart rate was
adequately controlled, and the patient performed a good breath
hold. An arrhythmia or gating problem should be suspected.
B, Review of the electrocardiogram reveals the problem. The patient
has had a run of ventricular bigeminy during the scan. Application
of the normal reconstruction algorithm does not take this
arrhythmia into account. To overcome this, the electrocardiogram
is edited by tagging the premature ventricular contractions as
distinct early beats, as described. HR, heart rate; PVC, premature
ventricular contraction. C, After re-reconstruction, images are now
motion free and diagnostic.

CO MMENTS
This is an example of an arrhythmia occurring during
the CT scan. The ventricular bigeminy during the scan
and resultant variability in the R-R interval nullifies
the usually accurate assumption that a simple percentage
phase will consistently reflect the mechanical state and
position of the heart. In this example, all reconstruction
windows (black and white bars) are obtained from 75%

of the R-R interval. However, although the 75% phase


of a normal cardiac cycle length reflects diastasis (black
bars), a 75% phase of a shortened cardiac cycle actually
reflects early diastole, a completely different mechanical
state of the heart and a different position of the cardiac
structures within the chest. The image reconstruction
is a blend of these two mechanical states, resulting in a
disjointed and unusable CT data set.

16

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

When this occurs, early beats must be tagged as distinctly different, premature beats, which the reconstruction
software will then treat differently. Because shortened
cycles will not have a late diastolic phase available, reconstruction of a 75% phase axial data set with this corrected

Case 7

ECG will use only data from the normal cardiac cycle
length beats and will skip over the data from the shortened
cardiac cycles. This kind of manipulation can salvage a
scan, but is only possible with helical cardiac CT.

Patient Selection: Coronary Calcification

A 69-year-old woman was referred for coronary CT angiography for the evaluation
of a 1-month history of episodic chest discomfort. She had a history of known
coronary disease, including an anterior myocardial infarction and percutaneous
transluminal angioplasty without stenting 6 years previously. A prospective, ECGtriggered cardiac CT scan was performed (Fig. 2-7).

B
n Figure 2-7 A, Plaque burden was heaviest in the proximal left
descending coronary artery, the location depicted by this image. The
arrows indicate two regions of especially prominent calcification.
Application of the usual image reconstruction methods results in
significant volume averaging of these calcifications (so-called
blooming), which obscures the coronary lumen and renders this
segment uninterpretable. Focal stenosis at this location cannot be
confidently excluded. B, Calcium burden in the segment is moderate,
but not extreme; hence, it may be possible to re-reconstruct the image
in a fashion that can render a diagnosis. In this image, the same data set
has been reconstructed with optimizations to reduce the volume
averaging of the calcium, such that the coronary lumen can now be
visualized and is appreciated to be well opacified by a continuous
column of contrast. These features help to exclude the presence of
stenosis in this segment. C, The angiogram of the same patient,
performed 3 months later for recurrent chest pain, confirms the absence
of angiographic stenosis in this segment (arrow). In some cases,
angiography of these calcified segments may underestimate actual
stenosis severity. In such cases, the lesion on invasive angiography can
appear hazy, but this characteristic is not seen in this case.

Chapter 2

CO MMENTS
Coronary calcification is frequently encountered in
coronary CT imaging because of the nature of the disease
process and the population referred for this test. Dense
coronary calcification can frequently be a reason for a scan
to be nondiagnostic. Because of its relatively high radiodensity compared with soft tissue and contrast, the standard reconstruction algorithms, which are not designed
for calcium, usually result in this type of calcium volume
averaging. To counteract this effect and render a usable
image, one should re-reconstruct the data with a sharper

Case 8

Optimizing CT Image Quality

17

kernel, increased image enhancement, a wider window,


and thinner slice thickness. If the calcium burden is not
too heavy, diagnostic images can be produced. There is a
limit to these tricks, however, and beyond a certain burden
of dense calcification, nothing can render a diagnosis. If
the calcium score is known to be very high before the CT
scan, caution should be exercised: the higher the score is,
the more likely it is that coronary CTwill render an inconclusive result. Patients with significant symptoms and very
high calcium scores should be considered for stress testing
or invasive angiography in lieu of coronary CT.

Patient Preparation: Respiratory Motion

A 76-year-old man presented for coronary CT angiography. A helical cardiac CT


scan was performed (Fig. 2-8). His heart rate during the scan was 62 bpm with
a regular rhythm.

n Figure 2-8 A, Despite the low heart rate and regular rhythm,
image quality is poor. This axial image demonstrates motion artifact
in the proximal right coronary artery (arrow), represented by a
blurred and broken appearance of the vessel. The appearance is
consistent with typical cardiac motion artifact, but this is unlikely
given the slow and regular rhythm. B, Examination of the lung
windows reveals the source of the problem. Streaks producing a
seagull appearance of the lung vasculature and adjacent
abnormally low-density areas indicate lung motion (arrow), i.e.,
breathing, during the scan. Unfortunately, there is no way to correct
for this using post-processing. C, The presence of respiratory
motion artifact can have a significant impact on accuracy. Here, in
another case, respiratory motion produces a pseudo-stenosis in the
left descending coronary artery (arrow). This patient had to be
rescanned after further breath-hold coaching, and the repeat scan
confirmed that no stenosis was present.

18

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

COMMENTS
Respiratory motion artifacts pose significant problems
for image quality. The consequences can be significant,
and respiratory motion can produce convincing
pseudo-lesions. One should be wary of any lesion in
which the plaque that causes the stenosis cannot itself
be visualized. Potential stenoses that appear blurry or
fuzzy or indistinct should be closely scrutinized. To look

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Chapter

Contrast Medium Administration


Dominik Fleischmann

KEY POINTS
l

Arterial enhancement after an intravenous contrast medium (CM) injection is controlled


by the injection rate and the injection duration.

The main physiologic parameter that controls arterial enhancement is cardiac output
(CO). High CO is associated with low opacification, whereas low CO results in stronger
opacification.

Increasing the scanning delay and the injection duration can be helpful when a small
intravenous cannula does not allow injection at a desired flow rate by providing a longer
duration to achieve adequate opacification.

For assessment of the right ventricle and the interventricular septum (e.g., for a left
ventricular mass and function), the right ventricular chamber needs to be at least slightly
opacified by flushing with diluted CM.

If bright pulmonary and systemic enhancement is desired, such as in patients with suspected acute aortic/coronary syndrome and pulmonary embolism, the injection duration
needs to equal the scan time (e.g., 10 seconds) plus the time it takes for the bolus to travel
from the pulmonary to the systemic circulation (pulmonary-to-systemic transit time).

Myocardial enhancement has substantially slower enhancement dynamics than vascular


opacification, therefore requiring comparably large CM volumes.

Empirical scan delays for a venous phase for cardiac masses are in the range of 1 to
2 minutes and approximately 5 minutes post-injection for myocardial viability.

19

20

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 1

Basic Contrast Medium Injection Protocol for Coronary


Computed Tomography Angiography

A 48-year-old business executive presented with an equivocal stress echo showing a


possible posteroinferior wall motion abnormality. He was referred for coronary
computed tomography angiography (CTA) to rule out coronary artery disease
(Fig. 3-1).

Inj. Duration
(scan time + 8 s)
Inj. Rate Weight
(mL/s)
(kg)

18 s
20 s
22 s
(10 + 8)
(12 + 8)
(14 + 8)
Contrast medium
volume (mL)

4.0

<55 kg

72

80

88

4.5

5565

81

90

99

5.0

6585

90

100

110

5.5

8595

99

110

121

6.0

>95 kg

108

120

132

12-s scan

300

200

100

0 8 16 24 32

0
12-s scan

5 mL/s for 20 s

400

300

200

100

400

delay

0 8 16 24 32

delay

Enhancement (HU)

Injection rate (mL/s)

5 mL/s for 12 s

0 8 16 24 32 40 48 56 64 72 80
Time (s)

n Figure 3-1 A, Volume-rendered images show no significant stenoses. Bright opacification of


the coronary arteries was achieved with a standard contrast medium (CM) injection protocol.
The parameters of this 12-second computed tomography (CT) scan were an injection rate of 5 mL/s, an
injection duration of 20 seconds (!100 mL CM volume), a scanning delay of CM transit time (tCMT)
8 seconds (where tCMT is determined by automated bolus triggering). B, The two key parameters for any
cardiovascular CT CM injection are CM injection rate (e.g., 5 mL/s [46 mL/s]), and the CM injection
duration, which is chosen to equal the scan time plus a few more seconds (38 seconds), to allow
increased arterial opacification. The injection rate can be adjusted for body weight and the injection
duration is 8 seconds longer than the scan time. C, Arterial opacification can be improved by increasing
the injection duration and the scanning delay. Instead of a 12-second injection for a 12-second scan (top),
one can increase the injection duration (e.g., 8 seconds) to a total of 20 seconds (bottom). The scanning
delay is also increased 8 seconds relative to the tCMT. The longer injection duration and delay result in
stronger enhancement, correctly synchronized with the CT data acquisition.

Chapter 3

21

When the injection duration is longer than the CT


scan time, then the scanning delay should be increased
proportionally to move the CT data acquisition toward
the later and greater peak (Figs. 3-1C, bottom, and
3-2C ).
The strength of arterial enhancement (for a given
CM injection) varies greatly among different patients.
The main physiologic parameter that controls arterial
enhancement is cardiac output (high CO is associated
with low opacification, whereas low CO results in stronger opacification). Because CO is usually unknown for
a given patient, adjusting the injection flow rate (and
volume) to a patients body weight is reasonable. This
will not eliminate but will at least reduce interindividual
variation in the degree of arterial enhancement.

CO MMENTS
Arterial enhancement after an intravenous CM injection
is controlled by two parameters: (1) the injection rate
(in milliliters per second), and (2) the injection duration
(in seconds). The CM volume is merely a derived
parameter (A  B). The injection rate (or, more precisely, the iodine flux) is directly proportional to arterial
enhancement. Arterial enhancement is also proportional
to the iodine concentration of the contrast agent.
We use high-concentration agents for cardiovascular
CT applications (e.g., 370 mg iodine/mL). The effect
of the injection duration on arterial enhancement is more
difficult to appreciate. As shown in Figure 3-1C, arterial
enhancement is not at all plateau-like, but increases
cumulatively over time. A short peak is followed by a rapid
decrease in opacification. Longer injection durations
therefore result in stronger arterial enhancement and a
later occurrence of peak enhancement.

Case 2

Contrast Medium Administration

Scanning Delay

Synchronizing the CT data acquisition (scanning) with strong arterial enhancement


requires that the scanning delay (the time interval between the start of an intravenous
CM injection and the start of the CT data acquisition) is individualized to a patients
CM transit time (tCMT). The tCMT is the time needed for CM to travel from the
intravenous injection site to the arterial region of interest. The tCMT can be
determined directly by using a test bolus, or indirectly by using automated bolus
triggering. In this case, a 66-year-old obese woman (115 kg) underwent coronary
CTA before gastric bypass surgery (see Fig. 3-2).

Enhancement (HU)

400

300

200

100

0
0

16

24

32

A
n Figure 3-2 A, The time-to-peak enhancement after an intravenous injection of a small test bolus of 15 to
20 mL reflects a patients contrast medium transit time (tCMT). The tCMT can either be used directly as the
scanning delay or as a relative landmark. For example, the scanning delay can be chosen to be slightly longer
than the tCMT. Increasing the scanning delay improves arterial enhancement. In this case, the test bolus was
16 mL, the injection rate was 4 mL/s, and the region of interest was the ascending aorta (shown on the left).
Arterial time attenuation response is shown on the right.
Continued

40

48

Time (s)

ROI vs Time

HU Enhancement

250
200
150
100
50
0

10

15

20

Time (s)

C
n Figure 3-2contd B, With automated bolus triggering, the full CM bolus is injected, while the
attenuation is monitored near real time within an arterial region of interest (ROI) (e.g., ascending aorta).
The scan is triggered when a preselected attenuation threshold is reached. The scanning delay achieved
with automated bolus triggering is always slightly longer than the true tCMT. It is again possible to further
increase the scanning relative to a patients tCMT. C, In this obese patient, only a small intravenous
cannula (20 gauge) could be inserted into a forearm vein, which limited the flow rate to 4 mL/s. Taking
advantage of the fact that arterial enhancement increases over time, we chose a very long injection duration
(35 seconds) and a long scanning delay (tCMT 18 seconds) to allow adequate arterial opacification
(390 Hounsfield units [HU]). Total contrast medium volume was 140 mL.

22

Chapter 3

CO MMENTS
Individualizing the scanning delay is mandatory for cardiovascular CT because the tCMT varies greatly among
different patients and can be anywhere between 12 and
25 seconds or even longer. The injection of a small test
bolus is a reliable means to determine a patients tCMT.
If the tCMT is, for example, 20 seconds, then a scanning
delay of 20 seconds can also be selected. For short CT
scan times, however, it is recommended that the scan
delay chosen is greater than the tCMT because arterial
enhancement continues to increase. One can add
between 2 and 8 seconds to the tCMT, such as in case 1,
in which the scanning delay was set to tCMT
8 seconds.
The advantage of automated bolus triggering is that
it does not require the injection of a test bolus. Automated bolus triggering is a very robust technique to
synchronize the CT data acquisition with a patients
CM dynamics. It is important to be aware of the fact,
however, that automated bolus triggering always results
in a scanning delay that is slightly longer than the true
tCMT. This is for technical reasons because most

Case 3

Contrast Medium Administration

23

scanners need a few seconds after the threshold has been


reached to initiate the CT data acquisition: the monitoring images need to be reconstructed, the patient table
may need to be moved, and a prerecorded breathingcommand needs to be given. Therefore, the shortest
delay that can be selected after the threshold has been
reached may be between 2 and 8 seconds or more
(depending on the scanner model). This is not a disadvantage because a longer scanning delay results in stronger arterial enhancement; however, an increased
scanning delay needs to be accounted for by also
increasing the CM injection duration. For example,
when the scanning delay is 8 seconds longer than the
true tCMT, then the injection duration also needs to be
8 seconds longer (see Fig. 3-1C).
Increasing the scanning delay and the injection duration can also be helpful when a small intravenous
cannula does not allow injection at a desired flow rate.
Giving the bolus a long head start and allowing the opacification to build up over a long injection duration can
achieve adequate opacification even with a comparably
low injection flow rate (see Fig. 3-2C).

Right Ventricular Enhancement

A 68-year-old man underwent aortic root and coronary CTA for preoperative
evaluation of a left sinus of Valsalva aneurysm (Fig. 3-3).

n Figure 3-3 A short occlusion of the left descending coronary artery (arrow) is seen. The arrowheads
indicate sinus of Valsalva aneurysm. Although the left ventricular and systemic arteries are well opacified,
the right ventricle is completely flushed out (30 mL of saline solution chaser). Lack of right ventricular
opacification limits the evaluation of the akinetic interventricular septum (see inverted gray scale image on the
right). The basic injection strategy needs modifications if, in addition to systemic arterial enhancement, the right
ventricle or the pulmonary vasculature is of diagnostic interest. Soft-tissue enhancement is of interest in the
setting of masses and may play a role in the future as an alternative to magnetic resonance to assess for
myocardial viability/scarring. At least minimal opacification of the right ventricle is needed to identify the right
ventricular chamber and thus the interventricular septum. Pulmonary arterial enhancement is important if
a pulmonary embolism is a likely differential diagnosis in a patient with atypical chest pain (double rule-out).
In this setting, pulmonary enhancement needs to be strong. Both right ventricular and pulmonary arterial
enhancement can be accomplished by modifications of the basic injection protocol. Soft-tissue enhancement
(masses, myocardial enhancement) is usually assessed during a second delayed CT data acquisition.

24

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 4

Pulmonary Arterial Enhancement

An 84-year-old woman underwent CTA for evaluation of chest pain (Fig. 3-4).

n Figure 3-4 Injections


aimed at opacification of the
pulmonary and systemic
arteries need to account for the
pulmonary-to-systemic transit
time, which is usually less than
15 seconds. In this 84-year-old
woman with a contained aortic
rupture (arrows) and a small
pulmonary embolism
(magnified box), this was
achieved by using an injection
duration that is 15 seconds
longer than the actual scan
time (total injection, 25
seconds). The scan was
triggered in the pulmonary
artery with an additional 15second delay (pulmonary tCMT
15 seconds).

Case 5

Soft-Tissue Enhancement

A 37-year-old man underwent CTA for evaluation of a cardiac mass (Fig. 3-5).
n Figure 3-5 Evaluation of
cardiac masses benefits from
enhancement information,
which can be obtained using
nonenhanced (not shown),
arterial, and venous phase
acquisitions (1 minute after
injection). This preoperative
computed tomography
angiography of a 37-year-old
man with suspected carcinoid
metastases in the right
atrioventricular groove of the
right ventricle shows definitive
enhancement, from 40 HU
(Hounsfield units) in the early
arterial phase (left) to 90 HU in
the venous phase (right),
consistent with solid tumor.

COMMENTS FOR CASES 3 TO 5


Saline flushing after CM injection (2040 mL of normal
saline solution, flow rate equal to the preceding CM
injection) clears the superior vena cava and the right
heart from dense, poorly mixed CM and therefore
reduces streak artifacts. For assessment of the right ventricle and the interventricular septum (e.g., for left ventricular mass and function), the right ventricular

chamber needs to be at least slightly opacified. This


can be achieved, for example, by flushing with diluted
CM (e.g., 10%20%) instead of flushing with saline
solution alone.
If bright pulmonary and systemic enhancement is
desired, such as in patients with suspected acute aortic/
coronary syndrome and pulmonary embolism, the injection duration needs to equal the scan time (e.g., 10 seconds) plus the time it takes for the bolus to travel from

Chapter 3

the pulmonary to the systemic circulation (pulmonaryto-systemic transit time). This transit time can either
be measured using a test bolus with time-attenuation
curves obtained from the aorta and the pulmonary
artery, respectively, or one can simply assume a transit
time of less than 15 seconds (which has a wide error
margin). For the empirical protocol, the injection
duration for a 10-second scan would be 25 seconds.
The scanning delay is equal to the aortic tCMT or, if
the region of interest for automated bolus triggering is
placed in the pulmonary artery, it should equal the
pulmonary tCMT 15 seconds.
Parenchymal enhancement has substantially slower
enhancement dynamics than vascular opacification.
Comparably large CM volumes, adjusted for patient
weight are preferred, e.g., 0.5 g of iodine per kilogram
of body weight, because parenchymal enhancement correlates with extracellular fluid space. Empirical scan
delays for a venous phase for cardiac masses in the range
of 1 to 2 minutes have been used successfully. For dedicated delayed enhancement for myocardial viability, the
scanning delay is probably best approximately 5 minutes
after injection.

Contrast Medium Administration

25

SUGGESTED READINGS
Bae KT, Heiken JP, Brink JA: Aortic and hepatic contrast medium
enhancement at CT. Part II. Effect of reduced cardiac output in a
porcine model, Radiology 207:657662, 1998.
Fleischmann D: Use of high-concentration contrast media in multipledetector-row CT: Principles and rationale, Eur Radiol 13(Suppl 5):
M14M20, 2003.
Fleischmann D, Hittmair K: Mathematical analysis of arterial enhancement and optimization of bolus geometry for CT angiography using
the discrete Fourier transform, J Comput Assist Tomogr 23:474484,
1999.
Hittmair K, Fleischmann D: Accuracy of predicting and controlling
time-dependent aortic enhancement from a test bolus injection,
J Comput Assist Tomogr 25:287294, 2001.
Jacquier A, Revel D, Saeed M: MDCTof the myocardium: A new contribution to ischemic heart disease, Acad Radiol 15:477487, 2008.
Kerl JM, Ravenel JG, Nguyen SA, et al: Right heart: Split-bolus injection of diluted contrast medium for visualization at coronary CT
angiography, Radiology 247:356364, 2008.
Silverman PM, Roberts S, Tefft MC, et al: Helical CT of the liver:
Clinical application of an automated computer technique, SmartPrep, for obtaining images with optimal contrast enhancement,
AJR Am J Roentgenol 165:7378, 1995.
Van Hoe L, Marchal G, Baert AL, et al: Determination of scan delaytime in spiral CT-angiography: Utility of a test bolus injection,
J Comput Assist Tomogr 19:216220, 1995.
Vrachliotis TG, Bis KG, Haidary A, et al: Atypical chest pain: Coronary, aortic, and pulmonary vasculature enhancement at biphasic
single-injection 64-section CT angiography, Radiology 243:368376,
2007.

Chapter

Systematic Analysis of Cardiac CT


John A. Rumberger

KEY POINTS
l

The major processing tools required to interpret cardiac computed tomography (CT)
involve two-dimensional, three-dimensional, and four-dimensional (time-based) imaging
methods.

Begin with gross inspection of the study (adequacy of anatomic coverage, adequate contrast opacification, absence/presence of heart rate, or patient-related motion artifacts).

If the study is a retrospective-gated investigation, perform a qualitative/quantitative analysis of left and right ventricular size and function, chamber sizes, and aortic root and
thoracic aorta sizes and a gross inspection of cardiac valves.

Perform a systematic review of the coronary artery anatomy using an established segmental approach (such as the American Heart Association coronary segment classification)
beginning with the left main and then proceeding in order through the left anterior descending, left circumflex, and right coronary artery segments.

An appropriate clinical report summarizing the results of the study is very important and
should summarize the anatomic findings as well as include recommendations for patient
follow-up.

26

Chapter 4

Case1

Systematic Analysis of Cardiac CT

27

Clinical Case Summary

A 46-year-old man who presented with atypical chest pain and underwent a stress
nuclear examination demonstrating equivocal results (normal electrocardiographic
response, but possible ischemia in the inferior wall versus diaphragmatic attenuation)
was referred for coronary CT angiography. He has a family history of premature
coronary disease and has a mild increase in his total cholesterol (208 mg/dL). He was
referred for cardiac CT to assess the severity, if any, of his coronary artery disease
and then, pending results, provide recommendations for therapy and/or the need for
further testing/evaluation. Before contrast CT angiography, a noncontrast scan was
performed showing a coronary calcium score of 50 (using the Agatston method)
(mild), but places him in the 78th percentile for age and sex.

SYSTEMATIC APPROACH TO
INTERPRETATION OF CARDIAC CT
The 64-slice multidetector CT image sets for the case
presentation will include two separate data reconstruction files: thick-section, multiphase images (divided into
10% phase intervals throughout an entire cardiac cycle),
used for assessment of gross cardiac anatomy and
ventricular function, and one or more thin-section,
high-resolution images for detailed coronary artery evaluation. Additional comparative studies are presented to
augment certain discussions, as noted, to follow. The
content of these files is determined by the specific protocols defined for image reconstruction. Image acquisition
for cardiac CT using multidetector CT is through a
standardized method depending on the intent of the
examination, but the reconstructed images (using various reconstruction filters, defined by the end user) are
variable, depending on the laboratory protocol.
This chapter initially defines the tools used for digital
dissection of the reconstructed images for detailed analysis
of the components of a complete cardiac CT evaluation.
This is followed by a case presentation, illustrations, tables,
and images emphasizing the systematic review required in
all cardiac CTexaminations and include gross inspection,
evaluation of noncoronary structures, assessment of cardiac function, and evaluation of coronary artery anatomy
and plaque definition. Illustrations follow the complete

analysis of one specific clinical case, but are contrasted with


various pathologic findings from other case examples as
defined in the figures to follow.

IMAGING TOOLS USED FOR


ANALYSIS OF CARDIAC CT
The systematic review of a cardiac CT examination
requires gross and detailed analyses using a variety of
image-dissection tools, each with variable display and
image processing characteristics. These characteristics
involve viewing the images in variable display thicknesses (defined by the analyst, but generally referred to
as thin and thick sections) and include two-dimensional,
three-dimensional, and four-dimensional tools (the
fourth dimension being time, either singly changing display phase or as a cine displaying a continuous loop of
motion). Table 4-1 defines the standard designations
for these various tools and their individual imageprocessing characteristics and limits.

Step 1. Gross Inspection


The initial review of the cardiac CT examination should
be a general inspection for overall data/image quality
(Fig. 4-1). Particular issues are proper alignment/registration of the images, adequate contrast opacification,
and proper anatomic coverage of the study.

TABLE 4-1 Common Reconstructed Image Analysis Tools for Cardiac Computed Tomography Interpretation
NAME
Volume-rendering technique
Maximum intensity
projection
Multiplanar reformation
Curved multiplanar
reformation

2-D
TOOL

3-D
TOOL

4-D
TOOL

THIN
SECTION

N/A

N/A

N/A
N/A

{
{

X
X

THICK
SECTION
{

*Limit is a minimum of 1-mm thickness.


{
Equivalent to slice thickness.
{
Maximum is total image field of view.
2-D, two-dimensional; 3-D, three-dimensional; 4-D, four-dimensional; N/A, not available or not applicable.

COMMENTS
Broad dynamic viewing range
Maximum voxel intensity
display
Absolute voxel size/density
Absolute voxel size/density

28

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

n Figure 4-1 Volume-rendering


technique computed tomography (CT)
image from the right lateral view
showing proper alignment/
registration of the spine, sternum, and
heart from the root of the aorta to just
below the apex of the left ventricle.
The right coronary artery (RCA) is also
prominently displayed and has
appropriate contrast opacification.
Three-dimensional views are
invaluable in assessing the general
quality of the cardiac CT and review of
gross anatomy and are also an
essential part of bypass graft
identification.

Step 2. Systematic Review of Noncoronary


Structures
A general inspection of the major noncardiac structures
is often more easily accomplished using a variable thickness (510 mm in general) maximum intensity projection from cephalad to caudad (base to apex) in the
standardized transaxial imaging plane (imaging from
the foot or F viewpoint). The overall size and character
of noncoronary cardiac and major vessel anatomy should
include defining the diameters of the ascending and descending aorta and main pulmonary artery, the left atrial
appendage and left anterior pulmonary vein, the aortic
root and left atrium, the remaining pulmonary veins,
the aortic valve, the mid left ventricular cardiac chambers, the mitral valve, the inferior vena cava, and the
pericardium. All these assessments show the general cardiac and immediate extracardiac vascular anatomy to be
normal and intact (Fig. 4-2).

Step 3. Systematic Review of Cardiac Size


and Function and Valvular Motion
Noncoronary cardiac structures must be examined in
depth. Ventricular function is evaluated by reconstructions in a 10-phase study representing images reconstructed at 10% intervals of the cardiac cycle (0%90%).
Global and regional ventricular function can be
assessed noninvasively by a variety of current imaging
modalities including gated single-photon emission CT,
two-dimensional echocardiography, magnetic resonance
imaging, and gated cardiac CT. In fact, assessments of
ventricular function using cardiac CT were performed
and validated using electron beam CT (originally
termed cine CT) in the 1980s and early 1990s.

By 1999, the American Heart Association recognized


the ability to noninvasively define cardiac function by the
previously cited methods (in addition to the standard invasive contrast ventriculography) and published standards
on the standardization of clinical date presentation and
interpretation. Essentially, using any noninvasive method,
the displays for evaluation of cardiac function were suggested to be presented in three orthogonal cardiac planes:
the horizontal long axis (similar to the apical four-chamber
view in echocardiography), the vertical long axis (similar
to the apical two-chamber view in echocardiography),
and the short axis (Fig. 4-3). When reviewing ventricular
function, it is also often convenient to display images in a
format similar to the common mid ventricular views used
in invasive contrast ventriculography, which are also
orthogonal, that is, the left anterior oblique with cranial
angulations (cranial) and the right anterior oblique with
caudal angulations (caudal) (Fig. 4-4).
Qualitative and quantitative measurements of left ventricular size and global and regional systolic function were
initially validated using electron beam tomography and
are now possible, reliably using 16- to 64-slice multidetector CT. All commercially available computer workstations used to interpret cardiac CTare preprogrammed to
use the 10 (or more, which may more accurately identify
left ventricular end-systole and end-diastole) phases
reconstructed during the cardiac cycle to define global
and regional systolic function. The images are first oriented into the standardized horizontal long axis, vertical
long axis, and short axis cardiac orientations, and then
after defining the level of the mitral annulus on each
frame, automatic edge detection algorithms define the
chamber volumes in three dimensions (Fig. 4-5). Global
left ventricular chamber volumes for this case are given

Chapter 4

Systematic Analysis of Cardiac CT

n Figure 4-2 Systematic review of cardiac computed tomography (CT) for noncoronary structures.
Thin 5-mm maximum intensity projection from the transaxial plane as viewed from the foot (or F) view.
A, View of mid ascending aorta (29-mm diameter), main pulmonary artery (PA), and thoracic aorta (22-mm
diameter). B, View of left atrial appendage and left anterior pulmonary vein (ANT. PV). C, View of the
aortic root and the left atrium (37-mm diameter). D, View of remaining PV: left posterior (POST.)/inferior,
right anterior/superior, right posterior/inferior. E, View at the level of the sinus of Valsalva noting a
trileaflet aortic valve. F, View of anatomic positioning of the four cardiac chambers: left ventricle (LV),
right ventricle (RV), left atrium (LA), right atrium (RA). G, View of the mitral valve (MV); note the positions
and relative thicknesses of the anterior and posterior valve leaflets. H, View at the level of the inferior vena
cava (IVC) (35-mm diameter). I, View of the anterior pericardium (normal).

29

30

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE


Apex
17

Horizontal
Long Axis
(4 Chamber)
Apex
17

Vertical
Long Axis
(2 Chamber)

anterior
anterolateral

anteroseptal

Basal

interolateral

inferoseptal
inferior

B
n Figure 4-4 Traditional left anterior oblique (A) and right anterior
oblique (B) views at end-diastole at the mid left ventricular level.

anterior
anteroseptal

anterolateral

7
8
12
11

Mid-Cavity

10

interolateral

inferoseptal
inferior
anterior
13

septal

14
16
15

lateral
Apical

inferior

Short Axis

n Figure 4-3 Standardized views of the left ventricle. A, Cardiac


long-axis views: horizontal (top) and vertical (bottom) long axes.
B, Cardiac short-axis views: base of heart (top), mid left ventricle
(middle), apex (bottom).

in Table 4-2; all values are within the normal range, as


initially established in normal volunteers using electron
beam tomography. A time-volume curve is also generated
during the quantitative analysis (Fig. 4-6), analogous to
the result found using gated single-photon emission CT.
Assessment of regional systolic left ventricular function is best done viewing the 10-phase study as a

A
n Figure 4-5 Quantitative analysis of the left ventricle. Specialized
software available on all commercial postprocessing computer
workstations divide the chamber into the horizontal long axis, vertical
long axis, and mid left ventricular short axis and facilitate determination
of the plane of the mitral valve at all available cardiac phases (A).
Continued

Chapter 4

Systematic Analysis of Cardiac CT

31

n Figure 4-7 AVI movie of a maximum intensity projection image


from the 10-phase reconstruction displayed in the horizontal long axis.
In this view, the left ventricular wall motion in the interventricular
septal, apical, and lateral free walls is normal.

B
n Figure 4-5contd Once the mitral valve is identified, then
automated edge-detection software (B) defines the three-dimensional
borders of the left ventricular cavity.

TABLE 4-2 Global Left Ventricular Volumes Based on


the 10-Phase Image Reconstruction Data
46-YEAR-OLD MAN WITH ATYPICAL
CHEST PAIN

PATIENT
End-diastolic
volume
End-systolic
volume
Stroke volume
Ejection fraction

172 mL
65 mL
106 mL
62%

Time-Volume Graph

n Figure 4-8 AVI movie of a maximum intensity projection image


from the 10-phase reconstruction displayed in the vertical long axis.
In this view, the left ventricular wall motion in the anterior, apical,
and inferior walls is normal.

180
160

Volume (mL)

140
120
100
80
60
40
20
0

10

20

30

40

50 60
% R-R

70

80

90 100

n Figure 4-6 Left ventricular time-volume curve. Note the similarity


to standard information available from single-photon emission
computed tomography. Rates of systolic emptying and diastolic filling
can also be estimated from these data; the 0% phase would correspond
to the peak of the R wave on the electrocardiogram.

continuous cine loop, a four-dimensional movie loop,


as seen in Figure 4-7 (horizontal long axis), Figure 4-8
(vertical long axis), and Figure 4-9 (mid ventricular short
axis). These views further demonstrate normal regional
systolic function in all major myocardial regions.
For comparison purposes, Figure 4-10 demonstrates
abnormal regional function in a 58-year-old man with
shortness of breath.
Qualitative and, in some instances, quantitative assessment of cardiac valves can also be done using multidetector
CT. All four major valves can be variably imaged during a
routine study. Dynamic motion of the mitral valve and aortic valve is shown in Figures 4-11 and 4-12. The motion
during the cardiac cycle is normal for both valves. In contrast, Figures 4-13 and 4-14 show dynamic motion of the
mitral valve (in long-axis and short-axis perspectives,

n Figure 4-9 AVI movie of a maximum intensity projection image


from the 10-phase reconstruction displayed in the vertical long axis.
In this mid chamber view, the left ventricular wall motion in the septal,
anterior, lateral, and inferior walls is normal.

n Figure 4-10 For comparison, an example from one individual with


a previous myocardial infarction and known left ventricular
dysfunction is shown. This is an AVI movie of a maximum intensity
projection image from the 10-phase reconstruction for a 58-year-old
man with new-onset dyspnea at rest. The display is from the horizontal
long-axis view. Note the dyskinesis of the left ventricular apex and
circumscribed apical thrombosis.

n Figure 4-11 AVI movie of a maximum intensity projection image


from the 10-phase reconstruction. The display is from a basal short-axis
view demonstrating the motion of the mitral valve, which is normal.

n Figure 4-12 AVI movie of a maximum intensity projection image


from the 10-phase reconstruction. The display is from a shortaxis view at the level of the sinus of Valsalva demonstrating
a trileaflet aortic valve with unrestricted opening.

n Figure 4-13 AVI movie of a maximum intensity projection image


from the 10-phase reconstruction for a 75-year-old woman with a
holosystolic murmur and a faint diastolic rumble. The display is from a
horizontal long-axis view showing a thickened anterior leaflet of the mitral
valve with mildly restricted opening. The left atrium (bottom) is enlarged.

n Figure 4-14 AVI movie of a maximum intensity projection image


from the 10-phase reconstruction for a 75-year-old woman with a
holosystolic murmur and a faint diastolic rumble. The display is from a
basal short-axis view showing a thickened anterior leaflet of the mitral
valve with mildly restricted opening.

Chapter 4

Systematic Analysis of Cardiac CT

33

n Figure 4-15 Basal short-axis views of the mitral valve at maximum opening demonstrating planimetered valve areas (A, mitral valve
area 9.5 cm2) and a 75-year-old woman with systolic and diastolic murmurs (B, mitral valve area 5.3 cm2, mild mitral stenosis).

respectively) in a 75-year-old woman with a holosystolic


murmur and a diastolic rumble on physical examination.
Planimetry of the valvular annulus at peak opening can be
performed; Figure 4-15 shows this measurement in the
original case and the case of a 75-year-old woman.

Step 4. Systematic Review of Coronary


Artery Anatomy
The major divisions of the coronary arteries are shown
in Figure 4-16 and include the left main, proximal/

LM

P-LAD
D1

P-RCA
P-LCX
OM1
M-LCX
M-RCA

OM2

M-LAD
D2

PDA
D-LCX
D-RCA

D-LAD

n Figure 4-16 Schematic presentation of coronary artery anatomy


and designations for interpretation of cardiac computed tomography
(redrawn from original design from the American Heart Association).
The major divisions of the coronary arteries include the left main (LM),
proximal (P)/mid (M)/distal (D) left anterior descending (LAD) arteries,
the first and second diagonal arteries (D1, D2), the proximal/mid/
terminal left circumflex (LCX) arteries, the first and second marginal
arteries (OM1, OM2), the proximal/mid/distal right coronary artery
(RCA), and the posterior descending artery (PDA) and posterior lateral
branches.

mid/distal left anterior descending, the first and second


diagonal arteries, the proximal/mid/terminal left circumflex, the first and second marginal arteries, the proximal/mid/distal right coronary artery, the posterior
descending, and posterior lateral branches.
All available image processing tools (see Table 4-1)
should be considered as part of the coronary artery
review process, and it is important to use any or all to
assist in defining the segmental vascular anatomy. A plan
is also necessary and should include reviewing each coronary segment thoroughly before moving on to the next
in order; begin with the left main artery, proceed to the
left anterior descending artery and its major branches,
then evaluate the left circumflex/marginal vessels and,
importantly, establish coronary dominance (right vs.
left vs. co-dominance), concluding with evaluation
of the right coronary artery and its major branches;
examples of this systematic review of the coronary anatomy are illustrated in Figures 4-17 to 4-20.
As with any imaging modality, a systematic and routine method of evaluation should be pursued, and this
applies to analysis of the coronary arteries using cardiac
CT. Properly performed cardiac CT angiography will
allow excellent definition of the main and branch coronary arteries, although at present, vessels smaller than
1 mm are often not well evaluated.

Step 5. Report Generation and


Recommendations
An example of a formal report for this case is given in
Table 4-3. The systematic review of this patients cardiac
CT has shown normal cardiac anatomy, but nonobstructive and in some cases complex plaque in the left anterior descending artery and its branches.

n Figure 4-17 Thin-section (5 mm) maximum intensity projection images centered at the left main (LM) artery and viewed from the foot,
transaxial projection (A) and from the anterior projection (B). The LM artery is normal.

C
n Figure 4-18 A series of images completing the review of the left anterior descending (LAD) artery. A, Volume-rendering technique threedimensional left anterior oblique view of the LAD artery and the first diagonal artery. B, Angulated thin-section (5 mm) maximum intensity
projection of the proximal and mid LAD artery demonstrating the eccentric nature of the atherosclerotic plaque. C, Angulated thin-section (5 mm)
maximum intensity projection of the mid and distal LAD artery, again demonstrating the eccentric nature of the plaque. D, Angulated thin-section
(5 mm) maximum intensity projection of the distal and apical LAD artery; note that the apical LAD artery is normal.
Continued
34

Chapter 4

Systematic Analysis of Cardiac CT

35

n Figure 4-18contd E, Angulated barrel-rolled thin-section maximum intensity projection centered on the proximal first diagonal artery
demonstrating the complex or mixed plaque (calcified and noncalcified) near its origin. F, Curved multiplanar reformation of the entire
LAD artery from the left anterior oblique view. G, Curved multiplanar reformation of the entire LAD artery from the orthogonal right anterior
oblique view.

n Figure 4-19 Angulated thin-section (5 mm) maximum intensity projection of the left circumflex/first obtuse artery; this vessel is normal and
nondominant.

It is necessary to present the information in a formalized report that details the results and, depending on
the situation, may provide additional recommendations
regarding therapy and/or the need for further cardiac
testing. There are several approaches to cardiac CT
angiography interpretation, and some authorities favor
following the approach used in conventional coronary
arteriography of stating values or ranges for coronary
stenoses. However, cardiac CT facilitates not only visualization of the lumen but also insight into the components of the plaque and an estimation of the focal and
global extent of plaque. A general philosophy for reporting coronary analyses for cardiac CT falls into three
clinical categories:

1. Normal coronary anatomy: no focal calcified or noncalcified plaque.


2. Abnormal, but without obstructive disease: variable
levels of plaque severity and compositions, but no
evidence of obstructive coronary disease; medical
therapy is suggested with the level of aggressiveness
consonant with the severity of plaque disease.
3. Abnormal, with possible or likely obstructive disease:
further testing or evaluation including stress testing
or invasive angiography is suggested, in addition to
medical therapy

36

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

n Figure 4-20 A series of images completing the review of the right coronary artery (RCA). A, Volumerendering technique three-dimensional right anterior oblique view of the proximal and mid RCA.
B, Volume-rendering technique three-dimensional inferior aspect view of the distal RCA, the posterior
descending artery (PDA), and posterolateral branches of the RCA; this is the dominant vessel. C, Angulated
thin-section (10 mm) maximum intensity projection of the proximal, mid, and distal RCA; the spatial
orientation of the RCA often allows the major aspects to be seen in such a view with cranial tilt; the
proximal and mid RCA is normal, but note two areas of calcified plaque in the periphery of the RCA. The
exact positioning of this plaque, however, is difficult from just one view. D, Angulated thin-section (5 mm)
maximum intensity projection of the PDA and posterolateral artery; here we note that the mild eccentric,
nonobstructive plaque seen in C is actually localized to the posterolateral branch. E, Curved multiplanar
reformation of the RCA from a right anterior oblique view. F, Curved multiplanar reformation of the RCA
from a left anterior oblique view; note the mild plaque in the most distal segments of the vessel.

TABLE 4-3 Detailed Cardiac Computed Tomography Report


Patient name
Patient sex
Referring physician
Modality
Summary of findings and
recommendations

NM
Male
64-slice multidetector CT with cardiac CT protocol
Normal left ventricle size and global systolic function. Normal valvular function and extracoronary cardiac
anatomy. There is mild eccentric, nonobstructive plaque in the mid lateral anterior descending artery, first
septal branch, first diagonal branch, distal right coronary artery, and posterolateral branch. There is also
mild eccentric but complex (calcified and noncalcified) nonobstructive plaque in the large second diagonal
branch. Finally, there is moderate eccentric, but nonobstructive plaque in the distal lateral anterior
descending artery. The nondominant left circumflex artery is normal, and the proximal and mid right
coronary artery is normal. The coronary calcium score is 50, placing the value at the 78th percentile
for age.
There is no evidence of obstructive coronary disease, and no further cardiac testing is suggested at this time;
however, an aggressive risk factor intervention program should be initiated.

Chapter 4
Indication

Procedure

Detailed interpretation
Left main artery
Left anterior descending artery
Proximal
Mid
Distal
First diagonal artery
Second diagonal artery
Left circumflex artery
Proximal
Mid
Distal
First marginal artery
Second marginal artery
Right coronary artery
Proximal
Mid
Distal
Posterior descending artery
Posterolateral artery
Left ventricular function
Size
Wall motion
Ejection fraction
Left atrium, right atrium,
right ventricle
Pericardium
Coronary calcium score

Systematic Analysis of Cardiac CT

37

NM is a 46-year-old man with a family history of premature coronary artery disease, high cholesterol, and
atypical chest pain. He had a stress test, and the results were equivocal for ischemia in the inferior left
ventricular wall. I have reviewed the clinical record and/or nursing notes and agree with the clinical
indications for the requested cardiac CT procedure.
Oral metoprolol and sublingual nitroglycerin (0.4 m) was given before imaging. A noncontrast CT scan of the
heart was done using a standardized protocol to define the coronary calcium score. This was immediately
followed by contrast-enhanced CT imaging of the heart, coronary arteries, and proximal great vessels,
performed using a 64-slice CT scanner. Total amount of IV contrast administered was <100 mL.
The patient was observed for at least 15 minutes after the procedure, and then the IV line was removed.
There were no complications, and the patient was discharged with instructions to force fluids the
remainder of the day. The images were reviewed on an independent computer workstation with thin-section
two-dimensional and three-dimensional volume images.
Normal
Normal
Mild eccentric, nonobstructive plaque
Moderate eccentric, but nonobstructive plaque
Mild eccentric, nonobstructive plaque
Mild eccentric, but complex (both calcified and noncalcified) nonobstructive plaque
Dominance no
Normal
Normal
Normal
Normal
Normal
Dominance yes
Normal
Normal
Mild eccentric, nonobstructive plaque
Normal
Mild eccentric, nonobstructive plaque
Normal; 172 mL end-diastolic volume
Normal in all myocardial segments
62%
Normal left atrium, right atrium size, and normal right ventricle size and systolic function
Normal
50; 78th percentile for age and sex

CT, computed tomography.

SUGGESTED READINGS
American Heart Association Committee Report: A reporting system
on patients evaluated for coronary artery disease, Circulation
51:734, 1975.
Budoff MJ, Shinbane J, editors: Cardiac CT Imaging: Diagnosis of Cardiovascular Disease, London, 2007, Springer-Verlag.
Cerqueira MD, Weissman NJ, Dilsizian V, et al: Standardized myocardial segmentation and nomenclature or tomographic imaging of the
heartA statement for healthcare professionals from the Cardiac
Imaging Committee of the Council on Clinical Cardiology of the
American Heart Association, Circulation 105:539542, 2002.
Hecht H, Budoff MJ, Berman D, et al: Coronary artery calcium scanning: Clinical paradigms for cardiac risk assessment and treatment,
Am Heart J 151:11391146, 2006.
Pelberg R, Mazur W, editors: Cardiac CT Angiography Manual, London,
2007, Springer-Verlag.

Rumberger JA, Feiring AJ, Marcus ML: Quantitation of ventricular


anatomy and volumes using cine CT. In Pohost GM, Higgins CB,
editors: New Concepts in Cardiac Imaging, vol. 4, Chicago, 1987,
Year Book Medical Publishers, pp 195216.
Standardization of cardiac tomographic imaging: The Cardiovascular
Imaging Committee, American College of Cardiology; The Committee on Advanced Cardiac Imaging and Technology, Council on
Clinical Cardiology, American Heart Association; and Board of
Directors, Cardiovascular Council, Society of Nuclear Medicine,
J Am Coll Cardiol 20:255256, 1992.
Stanford W, Rumberger JA, editors: Ultrafast Computed Tomographic
Cardiac Imaging: Principles and Practice, New York, 1992, Futura.
Wokak A, Gransar H, Thomson LEJ, et al: Aortic size assessment by
noncontrast cardiac computed tomography: normal limits by age,
gender, and body surface area, J Am Coll Cardiol Imag 1:200209,
2008.

Chapter

Coronary CT Angiography:
Normal Anatomy
Ricardo C. Cury and Roberto C. Cury

KEY POINTS
l

Cardiac computed tomography (CT) with excellent isotropic spatial resolution (0.4  0.4
 0.4 mm) can demonstrate simultaneously coronary and cardiac anatomy.

The modified American Heart Association coronary 17-segment model should be used for
describing the coronary anatomy in coronary CT angiography studies.

The American College of Cardiology/American Heart Association 17-segment myocardial


segmentation nomenclature should be used for describing the left ventricular myocardium
in function and perfusion cardiac CT studies.

Cardiac CT clearly demonstrates regional relationships between the coronary artery distribution and myocardial regions, in addition to coronary artery dominance and myocardial
segmentation.

Myocardial bridge is a common finding during coronary CT angiography (30% of cases),


and only a minority of cases may lead to complications, such as myocardial ischemia.

Normal coronary CT angiography anatomy can be


viewed within three-dimensional volume-rendered
images and axial images. Although volume-rendered

38

images are generally not used for specific coronary arterial diagnoses, they can serve as an aid to the overall anatomic relationships in the volume data set.

Chapter 5

Case 1

Coronary CT Angiography: Normal Anatomy

39

Normal Anatomy: Three-Dimensional Volume Rendering

Three-dimensional volume-rendered images of normal anatomy are shown in


Figure 5-1. The nomenclature used throughout follows the modified American
Heart Association 17-segment model of the coronary arteries: 1, proximal right

5
6
11
1

13

12
7

14

10

15

8
16
3

D
n Figure 5-1 A, Schema showing the modified American Heart Association 17-segment model of the coronary artery distribution. B, Threedimensional (3-D) volume-rendered image of right coronary artery showing the proximal (1), mid (2), and distal (3) coronary segments. The fourth
right coronary artery segment, the posterior descending artery, is not viewed in this projection. C, 3-D volume-rendered image from left main (5)
coronary artery that trifurcates into the left anterior descending (6, 7, 8, 9), left circumflex (11), and ramus intermedius (17) coronary arteries. D,
3-D volume-rendered image from the distal right coronary (3) bifurcating into the posterior descending (4) and posterior left ventricular (16) arteries.
Continued

40

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

E
n Figure 5-1contd E, 3-D volume-rendered image from the mid to distal left circumflex (13 and 15) and the second obtuse marginal
(14) coronary arteries.

coronary artery; 2, mid right coronary artery; 3, distal right coronary artery;
4, posterior descending artery of the right coronary artery; 5, left main coronary
artery; 6, proximal left anterior descending coronary artery; 7, mid left anterior
descending coronary artery; 8, distal left anterior descending coronary artery; 9, first
diagonal branch of the left anterior descending coronary artery; 10, second diagonal
branch of the left anterior descending coronary artery; 11, proximal left circumflex
artery; 12, first obtuse marginal branch of the left circumflex artery; 13, mid left
circumflex artery; 14, second obtuse marginal branch of the left circumflex artery;
15, distal left circumflex artery; 16, posterior left ventricular branch of the right
coronary artery; 17, ramus intermedius artery.

COMMENTS
The right and left coronary arteries arise from the aorta
just above the aortic valve: the left main arises from the
left sinus of Valsalva and the right coronary artery
(RCA) from the right sinus of Valsalva. The left main
artery courses to the left anteriorly and caudally and
divides into the left anterior descending coronary
artery (LAD) and left circumflex artery (LCX). Occasionally the left main artery can trifurcate with a ramus
intermedius branch bisecting the angle between the
LAD and LCX. The LAD travels anteriorly along the
interventricular groove, reaching or wrapping around
the apex, and gives off a number of diagonal and septal
branches. The LCX courses in the left atrioventricular

groove, giving off several obtuse marginal branches to


the lateral and inferolateral free walls of the left ventricle. The RCA courses to the right and anteriorly and
then turns caudally within the right atrioventricular
groove. The RCA gives the following branches: conus
branch (anterior course supplying the right ventricular
outflow tract), sinus node branch (posterior course supplying the sinoatrial node, acute marginal branches to
the free wall of the right ventricle, an atrioventricular
nodal branch (from the distal RCA), the posterior
descending artery to the inferior aspect of the interventricular septum, and posterior left ventricle (right
dominant supplying the inferior wall of the left
ventricle).

Chapter 5

Case 2

41

Coronary CT Angiography: Normal Anatomy

Axial CT Images

Axial CT images of normal anatomy are shown in Figure 5-2.

RCA
LAD
LAD

1 Diag

LM

LCX
LCX
GCV

LAD
1 Diag

RCA

LAD
1 Diag

OM1

OM1

LCX
LCX

GCV

n Figure 5-2 A, Axial view of multidetector computed tomography (CT) image (0.75 mm thick, 120 kV,
850 mA) showing the left main (LM) coronary artery arising from the aorta from the left sinus of
Valsalva and bifurcating into two branches: left anterior descending artery (LAD) and left circumflex artery
(LCX). B, Axial view of multidetector CT image showing the right coronary artery (RCA) arising from
the right sinus of Valsalva from the aorta (in red). 1 Diag, first diagonal branch; GCV, great cardiac vein.
C, Axial view of multidetector CT image shows the left anterior descending artery giving off the first
diagonal branch (in green) and the left circumflex artery giving off the first obtuse marginal (OM1) branch
(in orange). D, Axial view of multidetector CT image showing the mid portion of the three coronary
arteries and their branches. Note the great cardiac vein (in blue) in the left atrioventricular groove.
Continued

42

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

RCA
RCA

PDA
LCX

MCV

RI
LAD
1 Diag

n Figure 5-2contd E, Axial view of multidetector CT image showing the distal portion of the right
coronary artery giving off the posterior descending artery (PDA), parallel to the middle cardiac vein (MCV).
F, 3-D volume rendering from an anterior view of the heart showing the left main coronary artery, which
trifurcates in the left anterior descending artery, ramus intermedius (RI) artery, and the
left circumflex artery.

COMMENTS
A thorough understanding of coronary artery anatomy is
a prerequisite for correct diagnostic evaluation of CT
coronary angiography. Major coronary arteries are well
delineated and easy to evaluate on a good-quality CT
coronary angiogram obtained with the current CT technology. For a better understanding of the coronary anatomy, we follow and describe major coronary arteries in
contiguous axial CT images. There are two coronary
arteries originating from the aorta. The left main coronary artery arises from the left sinus of Valsalva and
courses to the left and posterior to the main pulmonary
artery. On the left side, the left main artery divides into
the LAD and LCX. The LAD runs anteriorly in the
anterior interventricular groove and gives off diagonal
and septal branches. The LAD can be followed to the
apex of the heart. The LCX runs in the left atrioventricular groove in the close proximity to the great cardiac
vein. The LCX gives off obtuse marginal branches that
supply the lateral wall of the left ventricle. The RCA
originates from the right sinus of Valsalva. The ostium

of the RCA is typically caudal to the origin of the left


main artery in axial slices. The RCA has a short horizontal proximal segment that runs anteriorly and to the
right. More distally, the RCA courses caudally in the
right atrioventricular groove. A reader can appreciate
the mid segment of the RCA in cross section in axial
images. The distal segment of the RCA is located in
the right atrioventricular groove on the inferior surface
of the heart and reaches the posterior crux of the heart.
The posterior descending coronary artery arises from
the RCA in 70% of the population (i.e., right dominance) and runs in the posterior interventricular groove
parallel to the middle cardiac vein. In 10% of the population, the LCX reaches the crux of the heart and continues as the posterior descending artery (i.e., left
dominance). In 20% of the population, the RCA gives
rise to the posterior descending artery, but the LCX
supplies the posterior left ventricular branch to the inferior wall of the left ventricle (i.e., balanced system or
co-dominance).

Chapter 5

Case 3

Coronary CT Angiography: Normal Anatomy

Myocardial Segmentation and Nomenclature for CT Imaging of


the Heart

Analysis of the ventricular chambers and myocardium proceeds along standard


orthogonal planes within the cardiac chambers. This technique is familiar because
similar views are obtained with two-dimensional echocardiography. Volumetric CT
data permit precise identification of correct cardiac axes. The sequential approach
presented in Figure 5-3 leads to a robust analysis of cardiac morphology.

LA

LV

RV

C
D
n Figure 5-3 Sequential approach to computed tomography (CT) imaging of cardiac planes. A, From an
axial CT data set at the level of the mitral valve, a longitudinal plane bisecting the mitral valve and the
left ventricular apex is used to create a two-chamber view. B, Vertical long-axis or two-chamber view
showing the left atrium (LA) and the left ventricle (LV). C, From the two-chamber view, a slice parallel to
the mitral annulus at the mid ventricular level is used to obtain a short-axis view. D, Short-axis view
showing the left ventricle and the right ventricle (RV).
Continued

LV

43

44

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

RV

LV

RA

LA

G
n Figure 5-3contd E, From the short-axis view, a slice bisecting the center of the LV and the
intersection between the junction of the free wall and diaphragmatic wall of the right ventricle are used to
obtain a true four-chamber view. F, Four-chamber view showing the left atrium, left ventricle, right atrium
(RA), and right ventricle. G, Multiple slices perpendicular to the septum and parallel to the atrioventricular
groove are used to obtain a stack of short-axis slices from base to apex. H, From a basal short-axis slice,
a plane bisecting the center of the left ventricle and the left ventricular outflow tract is used to obtain
a three-chamber view.
Continued

Chapter 5

Coronary CT Angiography: Normal Anatomy

45

Ao

LVOT

LA

LV

RA

AV RVOT

LA

K
n Figure 5-3contd I, Three-chamber view showing the left ventricular outflow tract (LVOT).
Myocardial thinning of the ventricular apex is a normal finding. Ao, aorta. J, From the three-chamber view,
a slice is used perpendicular to the aortic valve plane. K, Short-axis view showing the aortic valve (AV),
left atrium, right atrium, and right ventricular outflow tract (RVOT).

CO MMENTS
Systematic analysis of orthogonal planes through the
myocardial and associated structures provides a thorough evaluation of cardiac structures. This sequential

analysis forms the basis for detection of abnormalities


of myocardial structure including abnormalities of function, wall thickening, perfusion, masses, and anatomic
variants.

46

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 4

Left Ventricular Myocardial Segmentation

Left ventricular myocardial segmentation shown in Figure 5-4 follows the


American Heart Association 17-segment model, corresponding to general regions
of coronary blood flow distribution and providing a basis for standard nomenclature
for reporting.

C
n Figure 5-4 A, Myocardial segmentation of the left ventricle is divided in three short-axis views and the
apex: basal, six segments; mid, six segments; apical, four segments; apex, one segment. B, Myocardial
segmentation shown in a four-chamber view: basal (green), mid (blue), apical (red). C, Coronary artery
territories shown in a two-chamber view: Left anterior descending artery (LAD) (blue), left circumflex artery
(LCX) (green), right coronary artery (RCA) (red). D, Coronary artery territories shown in a short-axis view:
left anterior descending artery (blue), left circumflex (orange), right coronary artery (red).
Continued

Chapter 5

Coronary CT Angiography: Normal Anatomy

47

E
Vertical
Long Axis

Short Axis

Basal
1

Mid

Apical

Mid

7
13
14

12

16

17
9

11

15

10
4

LAD

RCA

LCX

n Figure 5-4contd E, Coronary artery territories: left anterior descending artery (blue), left anterior
descending/left circumflex arteries (green), left circumflex artery (orange), right coronary artery (red).
F, Schematic of coronary artery territories.

CO MMENTS
Although there is variability in the coronary artery blood
supply to the myocardial segments, it is appropriate to
assign individual myocardial segments to specific coronary artery territories. The general assignment of the
17 myocardial segments to one of the three major coronary arteries is shown in Figure 5-4F. The greatest

variability in myocardial blood supply occurs at the


apex, segment 17, which can be supplied by any of the
three arteries. Segments 1, 2, 7, 8, 13, 14, and 17 are
assigned to the LAD distribution. Segments 3, 4, 9, 10,
and 15 are assigned to the RCA when it is dominant.
Segments 5, 6, 11, 12, and 16 generally are assigned to
the LCX.

48

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 5

Myocardial Bridge: Normal Findings

A 36-year-old woman presenting with atypical chest pain and two risk factors
(smoking and hypertension) underwent coronary CT angiography to evaluate
the coronary arterial anatomy (Fig. 5-5).

C
n Figure 5-5 A, Three-dimensional volume-rendered image of the left anterior descending artery with a
myocardial bridge (green arrow). The mid portion of the coronary artery is not apparent along the epicardial
surface. B, Three-dimensional volume-rendered image from the left anterior descending artery with a
myocardial bridge now seen (green arrow) after excluding the myocardium above the coronary. C, Curved
multiplanar reformation image from left anterior descending artery with myocardial bridge (green arrow).
The artery leaves the interventricular groove, and the bridge is identified by the band of myocardium
superior to the arterial lumen.

Chapter 5

Case 6

Coronary CT Angiography: Normal Anatomy

49

Myocardial Bridge: Normal Findings

A 42-year-old woman was admitted to the emergency department with chest pain
that was relieved with rest. She recently had a positive stress test. She did not have
any known cardiac risk factors. An electrocardiogram and troponin were normal.
She underwent coronary CT angiography to evaluate the coronary arterial anatomy
(Fig. 5-6).
Myocardial bridging is usually a benign condition with
an excellent long-term survival but has been associated
with chest pain, myocardial ischemia, myocardial infarction, exercise-induced tachycardia, conduction disturbances, and sudden death.

LAD
Myocardial
Bridge

LV

n Figure 5-6 Curved multiplanar reformation image from left


anterior descending artery (LAD) with a myocardial bridge. There is
no evidence of obstruction or plaque. Calcium score is zero. LV,
left ventricle.

CO MMENTS
Myocardial bridging is an intramuscular segment of a
coronary artery seen most commonly in the LAD (mid
portion). They can also be found in the LCX and
RCA. The prevalence of intramuscular coronary artery
on CT (30%) is in concordance with pathologic reports
and higher than in angiographic series (from 0.8% to
4.9%). This is due to the different diagnostic criteria
of these two techniques: the diagnosis is based on the
anatomic relationships on CT versus dynamic (systolic)
arterial compression on invasive coronary angiography.

SUGGESTED READINGS
American Heart Association, American College of Cardiology, and
Society of Nuclear Medicine: Standardization of cardiac tomographic imaging, Circulation 86:338339, 1992.
Austen WG, Edwards JE, Frye RL, et al: A reporting system on
patients evaluated for coronary artery disease. Report of the Ad
Hoc Committee for Grading of Coronary Artery Disease, Council
on Cardiovascular Surgery, American Heart Association, Circulation
51:540, 1975.
Cerqueira MD, Weissman NJ, Dilsizian V, et al: American Heart Association Writing Group on Myocardial Segmentation and Registration for Cardiac Imaging: Standardized myocardial segmentation
and nomenclature for tomographic imaging of the heart, Circulation
105:539542, 2002.
Hendel RC, Patel MR, Kramer CM, et al: ACCF/ACR/SCCT/
SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for
cardiac computed tomography and cardiac magnetic resonance
imaging: A report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of
Cardiovascular Computed Tomography, Society for Cardiovascular
Magnetic Resonance, American Society of Nuclear Cardiology,
North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology, J Am Coll Cardiol 48:14751497, 2006.
Hoffmann U, Pena AF, Cury RC, et al: Cardiac CT in emergency
department patients with chest pain, Radiographics 4:963976, 2006.
Kalaria VG, Koradia N, Breall JA: Myocardial bridge: A clinical
review, Catheter Cardiovasc Interv 57:552556, 2002.
Konen E, Goitein O, Sternik L, et al: The prevalence and anatomical
patterns of intramuscular coronary arteries, J Am Coll Cardiol
49:587593, 2007.
Netter FH: The Ciba Collection of Medical Illustrations. The Heart: Coronary Arteries (vol. 5), 1971.

Chapter

Coronary CT Angiography:
Obstructive Coronary
Artery Disease
Stephan Achenbach

KEY POINTS
l

Coronary computed tomography (CT) angiography allows imaging of the coronary artery
lumen after intravenous injection of contrast agent.

Coronary CT angiography detects coronary artery stenoses with high accuracy if image
quality is sufficient.

Accurate grading of stenosis severity is not always possible with coronary CT angiography.

Coronary artery lesions in acute coronary syndromes often have a characteristic appearance. The vessel diameter is typically enlarged, and a rim of contrast agent may surround
the lesion. However, these features are not always present in acute coronary syndromes.

Image noise, calcification, motion, and slice misregistration can cause artifacts that may
mimic stenoses or obscure significant lesions.

50

Chapter 6

Coronary CT Angiography: Obstructive Coronary Artery Disease

51

Case 1
A 63-year-old man presented with a history of episodes of chest pain at rest that had
been occurring intermittently for approximately 8 weeks. Angina on exertion was
inconsistent. A stress electrocardiogram was inconclusive because of the inability to
exercise due to bilateral knee pain. A coronary CT angiogram was obtained to rule
out coronary artery stenoses (Fig. 6-1).

C
n Figure 6-1 A, Transaxial image (maximum intensity projection, 4-mm thickness) obtained by dual-source computed tomography (CT) after
intravenous injection of 55 mL of contrast agent. The distal left main coronary artery and the proximal to mid left anterior descending coronary
artery are seen. Some calcification can be appreciated along the course of the vessel. A short segment of high-grade stenosis is present (arrow).
The noncalcified plaque material that causes the obstruction is visible. B, Oblique maximum intensity projection. A longer segment of the
proximal and mid left anterior descending coronary artery is visualized (see inset for reference of image orientation). The lumen within the lesion
appears to be completely interrupted (arrow), which is the typical appearance of a very high grade stenosis in CT angiography (the limited spatial
resolution of CT does not allow visualization of the small remaining lumen). C, Curved multiplanar reformation. An image is reformatted along
a curved plane that follows the course of the artery through the data set (see inset for image orientation). The entire course of the left main and
left anterior descending coronary arteries is visualized. The stenosis of the left anterior descending coronary artery is clearly visible (arrow).
Continued

52

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

n Figure 6-1contd D, Three-dimensional surface-weighted volume rendering. The threshold for display is set to show the contrastenhanced lumen of the coronary arteries as well as the contrast-enhanced ventricular lumen. The outer walls of the coronary arteries (except
calcification) fall below the visualization threshold and are not displayed. The stenosis of the left anterior descending coronary artery is
visible (arrow). E, Invasive coronary angiography confirms a high-grade stenosis of the left anterior descending coronary artery (arrow).

Table 6-1 shows results of a meta-analysis of 54 studies published by


Vanhoenacker and colleagues and lists the pooled sensitivities and specificities of
coronary CT angiography for the detection of coronary artery stenoses using various
scanner generations. Sixty-fourslice CT permits the detection and exclusion of
coronary artery stenoses with a high degree of reliability if image quality is high.
Table 6-2 lists clinical scenarios in which the use of coronary CT angiography is
considered appropriate.
TABLE 6-1 Sensitivity and Specificity of Coronary CT
Angiography for the Detection of Coronary Artery
Stenoses
CT
SCANNER
TYPE
Per-segment
analysis
4-slice CT
16-slice CT
64-slice CT
Per-vessel
analysis
4-slice CT
16-slice CT
64-slice CT
Per-patient
analysis
4-slice CT
16-slice CT
64-slice CT

NUMBER OF
STUDIES

SENSITIVITY
(%)

SPECIFICITY
(%)

18
25
6

84
83
93

93
96
96

3
6
2

87
93
95

87
92
93

7
11
6

91
97
99

83
81
93

Adapted from Vanhoenacker PK, Heijenbrok-Kal MH, Van Heste R, et al:


Diagnostic performance of multidetector CT angiography for assessment of
coronary artery disease: Meta-analysis. Radiology 244:419428, 2007, with
permission.

TABLE 6-2 Clinical Scenarios in Which the Use of


Coronary CT Angiography is Considered Appropriate
1. Detection of CAD with previous test results: evaluation of chest
pain syndrome
Uninterpretable or equivocal stress test (exercise, perfusion,
or stress echo)
Intermediate pretest probability of CAD, electrocardiogram
uninterpretable, or patient unable to exercise
2. Detection of CAD: symptomatic, acute chest pain
Intermediate pretest probability of CAD, no electrocardiographic
changes and serial enzymes negative
3. Evaluation of coronary arteries in patients with new-onset heart
failure to assess etiology
4. Evaluation of suspected coronary anomalies
CAD, coronary artery disease.
Adapted from Hendel RC, Patel MR, Kramer CM, et al: ACCF/ACR/SCCT/
SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac
computed tomography and cardiac magnetic resonance imaging: A report of
the American College of Cardiology Foundation Quality Strategic Directions
Committee Appropriateness Criteria Working Group, American College of
Radiology, Society of Cardiovascular Computed Tomography, Society for
Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology,
North American Society for Cardiac Imaging, Society for Cardiovascular
Angiography and Interventions, and Society of Interventional Radiology. J Am
Coll Cardiol 48:14751497, 2006, with permission.

Chapter 6

Coronary CT Angiography: Obstructive Coronary Artery Disease

CO MMENTS
Detection of coronary artery stenoses is possible with
CT angiography if adequate equipment is used and
scans are performed and evaluated with sufficient
expertise. Although precise quantitative grading of
stenosis severity is not possible, the sensitivity and
specificity for the detection of high-grade luminal

53

obstruction (typically a stenosis severity of 50%) are


high. Display methods showing two-dimensional data
are usually best suited to analyze the coronary arteries.
In comparison, three-dimensional renderings can provide impressive visualization of anatomy in selected
cases, but are not a routine tool for evaluation because
they are prone to artifacts.

Case 2
A 53-year-old woman presented with mild atypical chest pain and a stress
electrocardiogram positive for ischemia in the inferior leads. Because a false-positive
stress test was suspected, a coronary CTangiogram (dual-source CT, 65 mL of contrast
agent) was obtained to rule out the presence of coronary artery stenoses (Fig. 6-2).

n Figure 6-2 A, Three consecutive transaxial images that display a cross section of the right coronary artery (arrows). In its mid segment, the right
coronary artery follows a course that is oriented orthogonally to the transaxial imaging plane so that a vessel cross section is displayed. Although in
the first image (left), the contrast-enhanced lumen of the right coronary artery is clearly visible, no clear contrast is visible in the second image
(middle) from a few millimeters further down along the course of the right coronary artery. Several millimeters further distally (right), the lumen is
visible again (a small side branch is also visible). This is the typical appearance of high-grade right coronary artery stenosis in the transaxial images
of which an original coronary computed tomography angiography data set typically consists. B, Oblique maximum intensity projection (8-mm
thickness) that displays the entire course of the right coronary artery. The short segment of stenosis is clearly visible (arrow). C, Curved multiplanar
reformatted image along the course of the right coronary artery. The stenosis is clearly visible (arrow).
Continued

54

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

n Figure 6-2contd D, Three-dimensional reconstruction. Again, the stenosis can clearly be detected (arrow). However, there is no
additional information beyond the two-dimensional images displayed in A through C. E, The corresponding invasive coronary angiogram
demonstrating the right coronary artery stenosis (arrow).

COMMENTS
Two-dimensional forms of image reconstruction are the
most accurate for detecting coronary artery stenosis.
This includes evaluation of the transaxial and orthogonal images and oblique multiplanar reformatted images

displayed in both thin and thick maximum intensity projections. The image quality in cases 1 and 2 is pristine,
leading to a straightforward evaluation, but more complex anatomy or degraded image quality can make interpretation more difficult (see the following cases).

Case 3
A 53-year-old male patient with a history of hypertension and smoking presented
to the emergency department because of acute chest pain. The resting
electrocardiogram and echocardiogram were normal, and initial evaluation of
myocardial enzymes failed to indicate myocardial necrosis. A coronary CT
angiogram was obtained to rule out coronary artery stenoses (Fig. 6-3).

Chapter 6

Coronary CT Angiography: Obstructive Coronary Artery Disease

55

n Figure 6-3 A, Cross-sectional computed tomography (CT) image in transaxial orientation showing a segment of the proximal left
circumflex coronary artery (arrow). This vessel segment is difficult to evaluate with regard to the presence of coronary stenosis because it is only
visualized over a short course and shows inhomogeneous contrast enhancement. B, A multiplanar reconstruction is rendered in an orientation
that corresponds to the course of the proximal left circumflex coronary artery (inset). The lesion is more clearly visible now (arrow), but
evaluation concerning the presence of stenosis remains problematic, mainly because it is unclear whether the interruptions in the contrastenhanced vessel lumen correspond to stenoses or are caused by vessel tortuosity. C, In the same orientation and plane as in B, a maximum
intensity projection is rendered (5-mm thickness). Now, a short eccentric stenosis can clearly be seen (large arrow). Proximal to this lesion, in
addition to a small calcification, a plaque ulceration can be appreciated (small arrow). D, Invasive coronary angiography (right anterior oblique
caudal projection) demonstrated an eccentric left circumflex coronary artery stenosis (large arrow) and a small plaque ulceration proximal to the
high-grade lesion (small arrow).

CO MMENTS
In cases of degraded image quality or complex anatomy,
evaluation of coronary CT angiography can be more

difficult and requires experience. Usually careful multiplanar reconstructions and maximum intensity projections will help to assess the presence of a luminal stenosis.

56

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Cases 4
through 6

Stenosis Severity

Cases 4 through 6 present some typical findings of coronary CT angiography in


stenoses of varying degrees (Figs. 6-4 to 6-6).

A
A

B
B
n Figure 6-4 A, Partially calcified coronary atherosclerotic lesion
with very mild luminal stenosis in the proximal left anterior
descending coronary artery, just distal to a small diagonal branch
(arrow). B, Corresponding invasive angiogram. Only a very slight
lumen reduction is detectable (arrow).

n Figure 6-5 A, Noncalcified stenosis of intermediate severity


visualized by contrast-enhanced computed tomography at the
bifurcation of the left anterior descending coronary artery and
diagonal branch (arrow). B, Corresponding invasive angiogram
showing a stenosis of intermediate degree involving both the left
anterior descending coronary artery and diagonal branch (arrow).

Chapter 6

Coronary CT Angiography: Obstructive Coronary Artery Disease

n Figure 6-6 A, Short high-grade stenosis of the left anterior


descending coronary artery (arrow) located at the bifurcation of the
left anterior descending coronary artery and diagonal branch.
B, Corresponding invasive coronary angiogram demonstrating a
short very high grade stenosis (arrow).

57

CO MMENTS
The spatial resolution of coronary CT angiography is
not sufficient to allow reliable precise quantitative
assessment of the degree of luminal narrowing. Grading

of coronary stenoses requires experience. In many cases,


stenoses seem more severe on coronary CT angiography
compared with invasive catheterization.

Case 7
A 64-year-old patient was hospitalized for an acute stroke. During the course of the
hospital stay, he reported chest pain. A coronary CT angiogram was obtained to
rule out coronary artery stenoses (Fig. 6-7).

58

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

n Figure 6-7 A, Maximum intensity projection in an oblique plane to visualize the proximal left anterior descending
coronary artery. The vessel is severely calcified. Despite the calcification, the absence of luminal contrast enhancement over a
relatively long distance can be appreciated (arrows). Although complete occlusion of a coronary artery cannot always be
reliably differentiated from very high grade stenoses, long lesions are more likely to represent total occlusions, as was the
case in this example. B, Maximum intensity projection in an oblique plane to visualize the proximal left circumflex coronary
artery. Again, the lumen is interrupted over a relatively long distance, which corresponds to total occlusion (arrows).
C, Curved multiplanar reconstruction of the right coronary artery. A stenosis that appears to be of moderate degree is present
in the very proximal segment (arrow). The lesion shows slight calcification and positive remodeling. D, Visualization of the
left ventricle in a plane that corresponds to a four-chamber view. A small thrombus can be seen in the apical region (arrows).
This thrombus constitutes a possible source of embolus, which may have led to the patients stroke.
Continued

Chapter 6

Coronary CT Angiography: Obstructive Coronary Artery Disease

59

G
n Figure 6-7contd E, Invasive coronary angiography (right anterior oblique cranial projection)
demonstrating total occlusion of the left anterior descending coronary artery just distal to a septal
branch (arrow). F, Invasive coronary angiography of the right anterior oblique caudal projection
demonstrating proximal occlusion of the left circumflex coronary artery (arrow). G, Invasive
angiography of the right coronary artery (left anterior oblique cranial projection) demonstrating a
mild luminal narrowing of the proximal right coronary artery (arrow). Compared with the computed
tomography finding (C), the degree of stenosis on invasive angiography appears to be less severe.

CO MMENTS
It is not possible to always reliably differentiate coronary
occlusions from high-grade stenoses in coronary CT

angiography because both can be associated with a loss


of luminal enhancement on CT. Long lesions are more
likely to represent total occlusions.

60

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 8
A 74-year-old patient presented with stable chest pain. Coronary CT angiography
was performed and demonstrated a long occlusion of the right coronary artery
(Fig. 6-8). The fact that there was no coronary calcification in the course of the
occlusion prompted an interventional approach to be taken to open the artery, which
was successful.

n Figure 6-8 A, Curved


multiplanar reconstruction of
the right coronary artery
demonstrating a long
interruption of the contrastenhanced lumen (arrows). This
corresponds to chronic total
occlusion. Although there is
some localized calcium at the
beginning of the occlusion, the
entire remaining vessel is not
calcified. B, Invasive coronary
angiography of the right
coronary artery. Proximal
occlusion of the vessel is
demonstrated (left, arrow).
Interventional recanalization is
successful (right).

COMMENTS
It has been demonstrated that the absence of coronary
calcification in CT angiography is an indicator of the
success of interventional recanalization of chronic total

coronary artery occlusions. This is one context in which


CT angiography may provide useful adjunct information
for planning complex interventions.

Chapter 6

Cases 9
through 11

Coronary CT Angiography: Obstructive Coronary Artery Disease

Plaque Calcification

Cases 9 to 11 demonstrate CT findings of coronary artery stenoses with varying


degrees of calcification (Figs. 6-9 to 6-11). Not all stenoses are associated with
calcification at the site of luminal obstruction. Especially in the setting of acute chest
pain, the absence of calcium in the culprit lesion or even in the entire coronary
system is possible. Conversely, the presence of calcification makes it more difficult to
assess lesion severity.

A
A

B
n Figure 6-9 A, High-grade stenosis of the proximal left
anterior descending coronary artery in a 39-year-old patient with
acute chest pain. No coronary calcium is detectable. The stenosis
(arrow) is located immediately distal to the origin of a diagonal
branch. B, Corresponding invasive coronary angiogram (arrow
indicates stenosis).

B
n Figure 6-10 A, High-grade stenosis of the proximal left
anterior descending coronary artery in a 68-year-old patient
with stable chest pain. The lesion is calcified but clearly
detectable (arrow). B, Corresponding invasive angiogram (arrow
indicates stenosis).

61

62

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

n Figure 6-11 A, Visualization of the proximal left anterior


descending coronary artery in a 73-year-old patient with substantial
coronary calcification. A high-grade stenosis is present immediately
proximal to the bifurcation of the left anterior descending coronary
artery and diagonal branch (large arrow). However, this stenosis is not
clearly visible because of a calcified plaque. Another calcified plaque
is found just proximal to the origin of the first diagonal branch (small
arrow). The first diagonal branch has a high-grade stenosis
(arrowhead). B, Invasive coronary angiogram. Although the proximal,
larger calcified plaque is not associated with a relevant stenosis (small
arrow), a high-grade stenosis is present at the site of the second
smaller calcification (large arrow). The arrowhead indicates the
stenosis of the first diagonal branch.

COMMENTS
Coronary artery stenoses may display varying degrees of
calcification. Severe calcification can make the assessment of stenosis severity extremely difficult. Both falsenegative and false-positive findings of stenosis are possible in the context of severe coronary calcification. Falsepositive findings are more frequent and occur especially

if motion artifact is present in addition to severe calcification. Calcified lesions are particularly prone to overestimation of lesion severity due to so-called blooming
of calcium. Tricks to diminish calcium blooming include
changing the reconstruction parameters (use of a
sharp reconstruction filter) or changing the display
settings to a wider CT window and center or level.

Case 12
A 46-year-old patient presented to the emergency department with atypical chest
discomfort. An initial ECG showed mild repolarization abnormalities in the inferior
leads, whereas myocardial enzymes were not elevated. A coronary CT angiography
examination was performed to rule out coronary artery stenoses (Fig. 6-12).

Chapter 6

Coronary CT Angiography: Obstructive Coronary Artery Disease

63

n Figure 6-12 A, Transaxial image at the level of the proximal right coronary artery. The artery is enlarged, and next to the remaining lumen,
a low-density structure surrounded by a rim of contrast agent can be seen (arrow). This finding is typical of a culprit lesion in an acute coronary
syndrome. B, Curved multiplanar reconstruction showing the right coronary artery in its entire course. The lesion in the proximal right coronary
artery is clearly visualized (large arrow). The vessel diameter is enlarged (positive remodeling), and there is inhomogeneous contrast enhancement.
Again, this appearance is typical of a culprit lesion in an acute coronary syndrome. A second high-grade stenosis is present in the mid segment of the
right coronary artery (small arrow). C, Cross-sectional rendering of the proximal right coronary artery (see inset for orientation). Next to the
remaining lumen, the low-attenuation filling defect and a rim of bright intensity can be seen (arrow). This most likely corresponds to a thrombus
surrounded by contrast agent and, if observed, is typical of acute coronary lesions. D, Invasive angiogram of the right coronary artery demonstrating
the proximal culprit lesion (large arrow) and a second high-grade stenosis in the mid segment of the right coronary artery (small arrow)

CO MMENTS
Acute coronary lesions often present with an enlargement of the vessel diameter and sometimes with a typical
ringlike enhancement, depicting thrombus with surrounding contrast agent. Typically, CT attenuation of

the plaque material is relatively low. Calcification, if


present, has been reported to often be spotty in such
acute culprit lesions. However, not all culprit lesions
have this appearance and optimal image quality is necessary to be able to demonstrate these findings.

64

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 13
A 56-year-old patient was admitted with acute chest pain and slight changes on the
resting electrocardiogram. Left ventricular function was normal on
echocardiography, and myocardial enzymes were normal. Coronary CT angiography
was performed to rule out coronary artery stenoses (Fig. 6-13).

n Figure 6-13 A, Coronary


computed tomography (CT)
angiogram (3-mm thick
maximum intensity projection)
in an oblique plane that
visualizes the left main and
proximal left circumflex
coronary arteries. The left
circumflex coronary artery is not
very large. Just distal to a small
calcification, the vessel shows a
short lesion (large arrow) with
complete interruption of the
vessel lumen. The lesion shows
pronounced positive
remodeling, as is often (but not
always) seen in acute coronary
syndromes. The arrowhead
indicates the distal left
circumflex coronary artery, and
the small arrows indicate the
great cardiac vein that follows a
course parallel to that of the left
circumflex coronary artery. B,
Visualization of a myocardial
perfusion defect (5-mm thick
slices). Although attenuation
within the left ventricular
myocardium appears
homogeneous in a normally
windowed four-chamber view
(left), relatively bright
windowing with strong contrast
allows detection of a clearly
delineated area of lower CT
attenuation in the posterolateral
wall of the left ventricle (arrows,
right). Such perfusion defects
are occasionally found in
acute coronary syndromes.
C, Invasive coronary angiogram
in the left anterior oblique
caudal projection
demonstrating occlusion of the
left circumflex coronary artery
(left, large arrow). Faint collateral
filling of the distal circumflex
vessel is detectable (small arrow).
The vessel was reopened (right,
small arrows indicate the distal
left circumflex coronary artery).
Subsequently, an increase in
myocardial enzymes confirmed
the acute coronary syndrome
(non-ST segment elevation
myocardial infarction).

Chapter 6

Coronary CT Angiography: Obstructive Coronary Artery Disease

CO MMENTS
Findings of myocardial hypoperfusion or regional wall
motion abnormalities can be observed in some patients
with acute coronary syndromes reflected by lower CT
attenuation values in the affected region. Especially if
the affected coronary vessel is smaller, visualization of

Cases 14
through 17

65

the culprit lesion may require careful image post-processing. When the distal vessel segment shows luminal contrast enhancement, reliable differentiation of a highgrade stenosis with anterograde flow from a complete
occlusion with collateral flow to the distal vessel segment is not possible with CT angiography.

Imaging Artifacts

Image quality in coronary CT angiography can be degraded by artifacts


(Figs. 6-14 to 6-17). In the presence of artifacts, assessment of stenosis severity
can be difficult and false-positive as well as false-negative findings can occur.
It is important to recognize typical artifacts to avoid misinterpretation.

n Figure 6-14 A, Coronary computed tomography angiography


in an obese patient. Obesity leads to increased image noise
(graininess of images) from soft-tissue attenuation of the x-rays.
As in this example, showing the very proximal right coronary artery
(arrow), image noise may make the assessment of the presence or
absence of coronary stenosis difficult. B, In the same patient, a
maximum intensity projection was obtained (5-mm thickness, same
slice position and orientation as in Fig. 6-13A). The thicker slices
reduce image noise, and a high-grade stenosis is now clearly visible
(arrow). C, Corresponding invasive angiogram confirming a highgrade stenosis (arrow).

66

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

C
n Figure 6-15 A, Coronary computed tomography angiography in a 68-year-old woman with
suspected coronary disease. The curved multiplanar reconstruction shows a short interruption of the
continuity of the vessel lumen, which is very suggestive of a coronary stenosis (arrow). B, A maximum
intensity projection of the right coronary artery in the same patient (coronal orientation) demonstrating
that the interruption of the vessel lumen is secondary to a misalignment artifact (also called step artifact
or slab artifact). These artifacts occur when, from one rotation of the scanner gantry to the next, the
coronary artery does not return to exactly the same position (e.g., due to respiratory motion or slight
arrhythmia). Here, the presence of such an artifact is easily recognized due the exactly horizontal borders
of the vessel proximal and distal to the suspected lesion (large arrow), due to the facts that a subtle line is
recognizable that extends through the entire data set exactly at the level of the lesion (small arrows) and
subtle misalignment artifacts can also be observed further proximally in the vessel (arrowheads).
C, Invasive angiography of the right coronary artery demonstrating the absence of coronary stenoses.

Chapter 6

Coronary CT Angiography: Obstructive Coronary Artery Disease

C
n Figure 6-16 A, Coronary computed tomography (CT) angiogram of the proximal left anterior
descending coronary artery (axial orientation) in a 69-year-old man with suspected coronary disease.
A dense calcification is present that does not allow visualization of the lumen (arrow) over a very short
segment. B, Longitudinal reconstruction of the vessel. Two discrete calcifications are visible (arrow).
C, Invasive angiography. A high-grade stenosis is present at the site of the calcification (arrow). This is a
rare case in which calcification causes a false-negative CT appearance of a coronary stenosis.

67

68

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

C
n Figure 6-17 A, Transaxial image of the proximal left anterior descending coronary artery in a
58-year-old man with chest pain. In addition to the calcification of the vessel wall, a significant stenosis
appears to be present in the very proximal left anterior descending coronary artery (arrow).
B, Longitudinal reconstruction of the proximal left anterior descending coronary artery. Again,
computed tomography suggests the presence of a high-grade lumen reduction (arrow). C, Invasive
coronary angiography. Only a mild lumen reduction is present in the very proximal left anterior
descending coronary artery (arrow). Coronary artery calcification, especially in combination with image
noise (as in this case) or motion, is a frequent reason for false-positive findings.

COMMENTS
Because of the limited spatial and temporal resolution of
coronary CT angiography, artifacts can degrade image
quality and lead to false-positive and false-negative
findings of stenosis. False-negative findings can be

caused by image noise, small coronary diameters, and,


infrequently, coronary calcification. False-positive findings can be a consequence of misalignment artifacts,
motion, and calcification; most frequently, the reason is

Chapter 6

Coronary CT Angiography: Obstructive Coronary Artery Disease

a combination of the latter two. In the setting of coronary calcification, it is important to optimize all other
imaging parameters, e.g., by carefully selecting the optimal time instant for image reconstruction to minimize
the influence of motion so that misdiagnoses are
avoided.

SUGGESTED READINGS
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coronary arterial stenosis, J Cardiovasc Comput Tomogr 1:320, 2007.
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Noninvasive risk stratification and a conceptual framework for the
selection of noninvasive imaging tests in patients with known or
suspected coronary artery disease, J Nucl Med 47:11071118, 2006.
Budoff MJ, Achenbach S, Blumenthal RS, et al: Assessment of coronary
artery disease by cardiac computed tomography: A scientific statement
from the American Heart Association Committee on Cardiovascular
Imaging and Intervention, Council on Cardiovascular Radiology
and Intervention, and Committee on Cardiac Imaging, Council on
Clinical Cardiology, Circulation 114:17611791, 2006.
Goldstein JA, Gallagher MJ, ONeill WW, et al: A randomized
controlled trial of multi-slice coronary computed tomography for
evaluation of acute chest pain, J Am Coll Cardiol 49:863871, 2007.
Hamon M, Morello R, Riddell JW, Hamon M: Coronary arteries:
Diagnostic performance of 16- versus 64-section spiral CT compared with invasive coronary angiographyMeta-analysis, Radiology
245: 720731, 2007.
Hendel RC, Patel MR, Kramer CM, et al: ACCF/ACR/SCCT/
SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for
cardiac computed tomography and cardiac magnetic resonance
imaging: A report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of
Cardiovascular Computed Tomography, Society for Cardiovascular
Magnetic Resonance, American Society of Nuclear Cardiology,
North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology, J Am Coll Cardiol 48:14751497, 2006.

69

Hoffmann U, Moselewski F, Cury RC, et al: Predictive value of 16slice multidetector spiral computed tomography to detect significant
obstructive coronary artery disease in patients at high risk for coronary disease. Patient versus segment-based analysis, Circulation
110:26382643, 2004.
Hoffmann U, Moselewski F, Nieman K, et al: Noninvasive assessment
of plaque morphology and composition in culprit and stable lesions
in acute coronary syndrome and stable lesions in stable angina by
multidetector computed tomography, J Am Coll Cardiol 47:
16551662, 2006.
Hoffmann U, Nagurney JT, Moselewski F, et al: Coronary multidetector computed tomography in the assessment of patients with acute
chest pain, Circulation 114:22512260, 2006.
Hoffmann U, Pena AJ, Cury RC, et al: Cardiac CT in emergency department patients with acute chest pain, Radiographics 26: 963978, 2006.
Leber AW, Knez A, White CW, et al: Composition of coronary atherosclerotic plaques in patients with acute myocardial infarction
and stable angina pectoris determined by contrast-enhanced multislice computed tomography, Am J Cardiol 91:714718, 2003.
Mollet NR, Hoye A, Lemos PA, et al: Value of preprocedure multislice
computed tomographic coronary angiography to predict the outcome of percutaneous recanalization of chronic total occlusions,
Am J Cardiol 95:240243, 2005.
Motoyama S, Kondo T, Sarai M, et al: Multislice computed tomographic characteristics of coronary lesions in acute coronary syndromes, J Am Coll Cardiol 50:319326, 2007.
Pugliese F, Mollet NR, Hunink MG, et al: Diagnostic performance of coronary CT angiography by using different generations of multisection
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Schroeder S, Achenbach S, Bengel F, et al: Cardiac computed tomography: Indications, applications, limitations, and training requirements: Report of a Writing Group deployed by the Working
Group Nuclear Cardiology and Cardiac CTof the European Society
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Eur Heart J 29:531556, 2008.
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coronary syndromes; non-invasive evaluation with multi-slice computed tomography, Acute Card Care 9:4853, 2007.
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Chapter

Detection of Calcified
Atherosclerosis
Allen J. Taylor

KEY POINTS
l

Coronary calcium quantitation is typically performed in axial images obtained at low peak
tube voltage and tube output with either electron beam or multidetector computed
tomography (CT).

Selection of patients according to published guidelines recommends restriction of this test


to asymptomatic patients without known coronary artery disease in whom global risk
prediction tools (such as the Framingham risk index) indicate an intermediate level of
coronary risk.

Coronary calcium is very simply quantitated using the area and density method. Care must
be taken to avoid foci of calcium in valves and the pericardium or artifacts due to excessively high image noise.

Coronary calcium prevalence and severity vary by age, race, and sex. White Americans have
more prevalent and severe coronary artery calcium than other ethnic groups.

Coronary calcium has a strong independent relationship to incident cardiovascular


outcomes, with up to a 10-fold relative risk for calcium scores higher than approximately
300.

Serial monitoring of coronary artery calcium progression is not currently endorsed by


guidelines due to uncertainty of its independent relationship to management and
outcomes.

70

Chapter 7

Case 1

Detection of Calcified Atherosclerosis

71

Detection of Coronary Calcium

A 64-year-old man presented for a pre-exercise physical evaluation. His cardiac risk
factors included pre-hypertension and low high-density lipoprotein cholesterol.
The calculated 10-year Framingham risk score was 16%, placing him at intermediate
risk of future coronary heart disease events (Fig. 7-1).

Detectors
Heart

LAD
Radiation
Shield
LM

Source
Collimator

LCX
CUUM
Chamber

Target Rings

B
4000

3500

16-MDCT Score

3000
2500
2000
1500
1000
500
0
0

500

1000 1500 2000 2500 3000 3500


Electron Beam CT Score

n Figure 7-1 A, Axial view multidetector noncontrast computed tomography (CT) images (2.5 mm thick, 120 kV, 100 mA) shown in thick section
with coronary artery calcium in the left main (LM), left anterior descending (LAD), and left circumflex (LCX) arteries. The total coronary artery calcium
score was 733 units quantified by the area-density method. Quantitation of coronary artery calcium is typically performed on 2.5-mm axial slices, using
the area and density (Agatston) method. Calcified lesions are detected based on their attenuation value, with an attenuation value of 130 Hounsfield
units (HU) as the threshold for a calcified lesion. Using this method, the area of calcification in each of the slices is calculated and multiplied by a
density-weighting factor from 1 (low-density calcium) to 4 (high-density calcium) based on the attenuation values of the lesion. The sum of all lesions
across the coronary tree is the total calcium score. The scores are typically reported separately for each coronary artery and as a total value. The total
value is the primary factor evaluated in the coronary risk factor assessment. A coronary artery calcium score of 0 indicates no detectable coronary
artery calcium. A score of 1 indicates the presence of at least three contiguous voxels meeting the threshold of 130 HU. Although any calcium score
greater than 0 is considered abnormal, low scores can be subject to error, particularly in obese patients, due to image noise from the low-energy CT.
B, The performance of noncontrast CT for coronary artery calcium was originally developed using electron beam scanner technology. The strength of
electron beam CT was its very high temporal resolution of 50 to 100 msec, which is enabled by rotation of the x-rays around the patient using an
electron gun. Scans were acquired in a step-and-shoot mode in which 35 to 40 continuous gapless slices of 1- to 3-mm thickness were acquired at
130 kV and a fixed tube output of 65 mA. The images were acquired in an electrocardiography-triggered mode at 40% to 80% of the R-R interval.
Radiation exposure for electron beam CT is low, at approximately 1 millisievert (mSv). C, Most scanners used today for calcium scanning are
multidetector scanners, and calcium scanning is performed as either a screening test or an initial noncontrast scan before contrast CT angiography.
Recommended scanner settings include acquisition in a triggered-mode (step and shoot) in late diastole, with a 0.625-mm collimation width. Typical
scanner settings include 120 kV and 50 mA (scalable). Images are reconstructed at 2.5- to 3-mm thickness. Radiation exposure for this technique is
approximately 1 mSv. It is important to stress that although calcium scanning can be performed using a spiral CT acquisition technique (using
retrospective gating, as often performed for CT angiography), radiation exposure with this scanner mode is unnecessarily high (four to five times
higher) and therefore not recommended. D, Agreement between electron beam CT and multidetector CT methods. Using comparable tube output and
voltage, there is excellent between-test agreement for electron beam CT and multidetector CT. Intertest agreement coefficients greater than 0.90 have
been reported. However, greater error is possible with multidetector CT at higher heart rates due to lower temporal resolution of the scanner and
artifact due to coronary motion.

72

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

COMMENTS
Selection of patients to undergo noncontrast CT is
guided by several professional society statements,
including the American College of Cardiology Clinical
Expert Consensus Document and the multisociety
Appropriateness Criteria for Cardiac CT. Selection of
intermediate risk patients (defined as a Framingham risk
level of 10% coronary heart disease risk over 10 years)
is judged as reasonable to refine the coronary heart
disease risk assessment (Table 7-1).
Coronary calcium quantitation is typically performed in axial images obtained at low peak tube voltage

and tube output. Classically performed using electron


beam CT, multidetector CT is now routinely used for
this application, given the comparability of the measurements. Low levels of radiation exposure accompany this
test if performed using appropriate scanner settings
including the acquisition in the prospective gated mode.
At present, selection of patients according to published
guidelines recommends restriction of this test to asymptomatic patients without known coronary artery disease
in whom global risk prediction tools (such as the
Framingham risk index) indicate an intermediate level
of coronary risk.

TABLE 7-1 Recommendations for Patient Selection for Noncontrast CT


YEAR
PUBLISHED

STATEMENT
American Heart Association Cardiac CT
Statement

2006

American College of Cardiology Expert


Consensus Document on coronary calcium

2007

American College of Cardiology Cardiac CT


Appropriateness Criteria

2006

Case 2

CONCLUSION
May be reasonable to measure the atherosclerosis burden using electron beam
or multidetector CT to refine clinical risk prediction and to select patients for
more aggressive target values for lipid-lowering therapies. Class IIb, level of
evidence: B
May be reasonable to consider use of coronary artery calcium measurement in
such patients based on available evidence that demonstrates incremental risk
prediction information in this selected (intermediate risk) patient group
Risk assessment: general populationasymptomatic calcium scoring
Inappropriate in low coronary heart disease risk
Uncertain appropriateness in moderate and high coronary heart disease risk
(Framingham)

Quantification of Coronary Calcium

A 45-year-old man with hyperlipidemia and a family history of coronary heart


disease (Framingham risk score of 6%) underwent coronary artery calcium scanning
(Fig. 7-2). The scan showed coronary artery calcium in the proximal left anterior
descending coronary artery and left circumflex coronary artery. The data were
transferred to an offline workstation for quantitative analysis.

n Figure 7-2 For legend, see next page.


Continued

Chapter 7

White (n = 1308)
1200
1000
800
600
400
200
0

CAC

CAC

90%
75%
50%

50

60 70 80
Age
Hispanic (n = 669)

50

60 70 80
Age
Black (n = 903)
1200
1000
800
600
400
200
0

90%
75%
50%

CAC

CAC

90%
75%
50%

50

60 70
Age

73

Chinese (n = 371)
1200
1000
800
600
400
200
0

90%
75%
50%

1200
1000
800
600
400
200
0

Detection of Calcified Atherosclerosis

80

50

60 70
Age

80

2 3a
4

Right

11
12

10

5
78 6

Left

Superior

Inferior

2 3a 4

10

5
20

6
30

8
40

9
50

10 11 12
60

70

Distance (mm)

n Figure 7-2contd A, A focus of coronary artery calcium is commonly defined with the scan matrix as the presence of three contiguous
voxels with a Hounsfield unit (HU) density of 130 or greater. In this figure, the HU density of coronary artery calcium typically is much greater
than 130, but a range of values exists within different atherosclerotic plaques. B, Coronary calcium was quantified using the area-density method.
In this method, plaques containing foci of calcium identified by the threshold as described in A are quantified by measurement of their area (pixel
size based on the scan field of view and display matrix) and density. A density-weighting coefficient of from 1 to 4 is applied, with more densely
calcified plaques (higher HU values) given higher weighting coefficients. These unitless quantification values are summed across the 35 to 40 CT
slices spanning the base to the apex of the heart, resulting in the calcium score. A score of 0 indicates the absence of detected coronary artery
calcium. Other methods for quantification of coronary artery calcium include the mass score and volume score. Calcium scores are dependent on
multiple factors including age, sex, ethnicity, family history, genetic factors, and measurable cardiovascular risk factors. C, Ethnic group
adjustments for calcium score distributions. Several studies have shown that ethnic groups systematically differ in the presence and severity of
coronary artery calcium. Whites are most likely to have coronary artery calcium present and to have higher coronary artery calcium scores.
Population data from the Multi-Ethnic Study of Atherosclerosis (MESA) are the best source of race-adjusted calcium score severity. Such
distributions are shown for white, black, Hispanic, and Chinese men. Scores are highest for white and lowest for Chinese Americans. CAC, coronary
artery calcium. D, The ethnic calcium score distributions are available at the MESA website (www.mesa-nhlbi.org). This site includes a calcium
scoring tool in which clinical patients can be compared with the MESA data. The calcium scoring tool indicates the likelihood of coronary artery
calcium in a patient of a given age, sex, and ethnicity and provides an estimate of the percentile ranking. CHD, coronary heart disease; HDL, highdensity lipoprotein; BP, blood pressure; CI, confidence interval. E, The MESA developed a new calcium scoring algorithm called the calcium
coverage score. This scoring method accounts for the degree of dispersion of coronary artery calcium across the coronary arterial tree.

74

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

COMMENTS
Workstation scoring of coronary artery calcium is a very
simple, computer-based technique using the area and
density scoring system. This method permits generalizability of calcium score data to published calcium score
distributions of the Multi-Ethnic Study of Atherosclerosis (MESA), which provide the most valid, population-

Case 3

based estimate of calcium score severity. Other calcium


scoring systems have not proven to be superior in risk
stratification for clinical practice. Whites and men have
more prevalent and more severe coronary artery calcium
at a given age. New methods of calcium scoring
accounting for the arterial coverage/spatial distribution
of coronary artery calcium may emerge in the future.

False-Positive Findings of Coronary Calcium

A 59-year-old woman with end-stage renal disease was referred for coronary
CTangiography due to suspicion of an anomalous coronary artery found on a
transesophageal echocardiogram. Coronary CTangiography confirmed an anomalous
left circumflex coronary artery arising from the right coronary artery. Noncontrast
cardiac CTwas performed initially to evaluate for coronary artery calcium (Fig. 7-3).

B
n Figure 7-3 A, Noncontrast computed tomography of the
coronary arteries shows no detectable coronary artery calcium. Due to
their abnormal calcium-phosphate metabolism, individuals with
renal failure are particularly prone to arterial calcification, and
evaluation of the calcium score for such patients within normal
population distributions is difficult. Despite the absence of coronary
artery calcium, aortic wall calcification is seen (arrow). Incidentally
noted is a dialysis catheter in the right atrium. B, Calcification is also
seen along the posterolateral segment of the heart. This is seen to be
in the region of the left circumflex artery but also near the annulus of
the mitral valve. Distinguishing these two locations is crucial to avoid
false-positive findings of left circumflex artery calcification. The
location of the coronary artery is within the atrioventricular groove
within low-attenuation (darker region, lower arrow) epicardial fat. In
comparison, the calcification shown in these images is in the region
of tissue density of the myocardium and blood pool and in the mitral
annulus (upper arrow). Calcification in this region should be excluded
from the coronary artery calcium score. The dialysis catheter is also
visible in the right heart. C, A thicker axial image shows the extent of
the mitral annular calcification in the typical location along the
posterior aspect of the heart (posterior to the posterior mitral valve
leaflet).

Chapter 7

Case 4

Detection of Calcified Atherosclerosis

75

False-Positive Findings of Coronary Calcium

A 38-year-old Hispanic woman with a body mass index of 39 kg/m2 has a small focus of
coronary artery calcium identified and a total coronary artery calcium score of 1 (Fig. 7-4).

n Figure 7-4 A, Although meeting the definition of a focus of


calcium (circle), small foci are prone to error in obese subjects due
to image noise as a consequence of the low tube output used in
the calcium scanning procedure. Similarly, small foci of calcium,
as may be evident on very sensitive techniques, such as
intravascular ultrasonography, may also be missed, although the
prognostic importance of such a small focus of coronary artery
calcium is not clinically different from a calcium score of zero.
Noise in coronary artery calcium scans is depicted as a granular
appearance of the scan data. Noise can be quantitated as the
standard deviation of the attenuation values in the image. B,
Coronary computed tomography angiogram showing a small
focus of calcification along the left coronary leaflet of the aortic
valve. In this instance, the contrast enhancement shows the
calcium clearly separated from the coronary arteries; the coronary
artery calcium score was 0.

CO MMENTS
False-positive findings of coronary artery calcium are
infrequent, yet attention must be paid to ensure that
any suspected focus of calcium lies within the coronary
artery distribution and not within the myocardium,

Case 5

pericardium, or valve planes. In overweight individuals,


image noise may create false-positive scan findings,
although such scores are generally very low and of minimal prognostic importance.

Application of Coronary Artery Calcium as a Prognostic


Tool in Preventive Cardiology

A 60-year-old white man has a total cholesterol of 184 mg/dL, high-density


lipoprotein of 44 mg/dL, and systolic blood pressure of 138 mm Hg. The
Framingham risk score is 12% for coronary heart disease events over 10 years,
placing him in an intermediate risk category. Multidetector CT for the detection of
coronary artery calcium shows a calcium score of 412. According to the MESA
calcium score distributions, 68% of 60-year-old white men will have a calcium score
above zero. A score of 412 is at the 88th percentile (Fig. 7-5).

76

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Summary RR Ratio CACS

RR

(95% CI)

Events/N
Higher Risk Low Risk*

Average Risk
Moderate Risk
High Risk
Very High Risk

1.9
4.3
7.2
10.8

(1.32.8)
(3.16.1)
(5.29.9)
(4.227.7)

67/9514
110/5209
182/3940
14/196

1112
100400
400999
1000

45/12,163
49/11,817
49/8649
6/905

0.01 0.1

Lower Risk

Coronary artery calcium score

12.5

>300
101300
1100
0

10.0
7.5
5.0
2.5
0.0
0.0

1.0

2.0
3.0
4.0
Years to Event

5.0

Cumulative Incidence of
Major Coronary Events (%)

Cumulative Incidence of
Major Coronary Events (%)

10

100

10

100

.001
<.0001
<.0001
<.0001

0.01 0.1

Higher Risk

Coronary artery calcium score

12.5

>300
101300
1100
0

10.0
7.5
5.0
2.5
0.0
0.0

1.0

2.0
3.0
4.0
Years to Event

5.0

C
Prevalence of Aspirin Use
Percent

60
50
40
30
20
10
0

Ba
se
lin
e

Ba

se

lin

Percent

Prevalence of Statin Use


60
50
40
30
20
10
0
1

Follow-up Year

2 3 4 5 6
Follow-up Year

Calcium = 0
Calcium > 0

Probability of Remaining
Event Free

1.00
0.95
0.90

n Figure 7-5 For legend, see next page.

Control

0.85
0.80

0.75
0
Treatment (n) 490
Control (n) 515

Treatment

P = .08
1

2
3
437
455
Years of Follow-up

4
414
417

Chapter 7

Detection of Calcified Atherosclerosis

77

n Figure 7-5contd A, The American College of Cardiology consensus document published a


meta-analysis of the relationship between coronary artery calcium and coronary heart disease outcomes.
According to this analysis, a calcium score of 412 places this patient in the high-risk category, with an
independent sevenfold relative risk (RR) of a coronary heart disease event. Studies contributing to this
analysis evaluated follow-up events over 4 to 8 years. Although the incidence of silent ischemia is
modest among asymptomatic individuals with calcium scores greater than 400, there are no formal
recommendations for routine stress testing because the therapeutic and outcome implications of this
approach are not understood. CACS, coronary artery calcium score; CI, confidence interval. B, The
Multi-Ethnic Study of Atherosclerosis (MESA) study also examined coronary outcomes in middle-aged
individuals 45 to 64 years of age. Calcium scores greater than 300 were associated with a more than
sevenfold relative risk of a major coronary event and 10-fold risk of any cardiovascular event over 5
years. C, The pattern of coronary artery calcium is another method to refine the coronary risk
assessment. The noncontrast computed tomography images show two different patients with a similar
coronary artery calcium score. One (left) shows spotty (small [<3 mm] foci of coronary artery calcium),
whereas the other (right) shows a very large area of coronary artery calcium in the left anterior
descending coronary artery. Greater numbers of calcified plaques and the presence of spotty
calcification are associated with greater risk. The distribution of coronary artery calcium also influences
the prognostic assessment. The finding of left main coronary artery calcium or three-vessel coronary
artery calcium is prognostically more important than two- or one-vessel coronary artery calcium. D, The
MESA developed an arterial age calculator by examining event risk as a composite function of risk factors
and coronary artery calcium. Applying the MESA arterial age calculator, which integrates coronary risk
factors and coronary artery calcium into an adjusted risk assessment, the patients estimated 10-year
coronary heart disease (CHD) event risk is approximately doubled to 25%. At this level, the patients risk
exceeds that of the National Cholesterol Education Program guideline level for secondary prevention
equivalent status, a threshold of 2% per year. The appropriate clinical response to this revised risk
assessment is to focus on modifiable risk factors and their treatment, in particular with revised, more
aggressive treatment targets. This approach is supported by the guidelines of the National Cholesterol
Education Program, which supports intensification of low-density lipoprotein (LDL)lowering therapy in
the setting of a calcium score above the 75th age and sex percentile. HDL, high-density lipoprotein;
BP, blood pressure; CAC, coronary artery calcium; CI, confidence interval. E, No study has addressed
whether an approach of calcium scanning improves overall net health care outcomes. Recent data have
demonstrated, however, that, in a community-based screening cohort, the detection of coronary artery
calcium led to a three- to sevenfold greater use of aspirin, statin, or their combination over 6 years. This
effect was independent of other cardiovascular risk factors. F, A single randomized trial addressed the
relationship between calcium screening guiding preventive therapy and statins. Among participants of the
St. Francis Heart Study with a coronary artery calcium score above the 80th percentile (n 1005),
randomization to atorvastatin treatment with 20 mg/day was associated with a 3% absolute risk reduction
(P .08) for composite cardiovascular events and a significant 6.3% absolute risk reduction in those with a
baseline calcium score greater than 400.

CO MMENTS
Multiple independent studies including young (4050
years of age) to elderly (older than 70 years of age)
populations have consistently shown a strong independent relationship between coronary artery calcium and
cardiovascular outcomes. The results of calcium scanning should be integrated with measured coronary risk
factors through methods such as use of the MESA arterial age calculator (www.mesa-nhlbi.org/Calcium/ArterialAge.aspx). A high calcium score denotes high relative
risk (calcium scores above the 75th percentile for age,
sex, and ethnicity) or absolute risk (for calcium scores
>300) for cardiovascular disease events. Both methods
(percentile score and absolute calcium score) identify
patients at increased risk of coronary heart disease;

Case 6

however, in younger patients, the percentile score primarily indicates relative risk, whereas the absolute risk
is associated with the total calcium score. Appropriate
selection or intensification of preventive therapies is
indicated in such patients to mitigate the heightened
coronary risk. In particular, a focus on full identification
of risk factors, lifestyle intervention, and cost-effective
pharmacologic therapies should be stressed. Treatment
guidelines should be closely followed by clinicians, and
adherence by patients to pharmacologic therapies is critical. Further outcome studies are needed on the impact
of coronary artery calcium testing on improving overall
net health outcomes, which will require randomized
clinical trials.

Serial Monitoring of Coronary Calcium

A 59-year-old man is self-referred for coronary artery calcium scanning on a


repeated basis (Fig. 7-6). The calcium score increased from 120 to 342 units on scans
2 years apart. He presents for interpretation of this finding.

78

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

A
800

1.0

<15% Change
Cumulative MI-Free Survival

Frequency

600

400

200

0
100

50

0
50
100
150
Annual CAC Progression

200

250

.9

.8

.7
15% Change
P < .0001
.6
0

3
4
5
Years of Follow-up

Erosions

Vulnerable plaques

n Figure 7-6 For legend, see next page.

Acute ruptures

none
speckled

speckled
fragmented
diffuse
Healed ruptures

none
speckled
fragmented
diffuse

none
speckled
fragmented
diffuse

Chapter 7

Detection of Calcified Atherosclerosis

79

n Figure 7-6contd A, Serial calcium scanning for detection of coronary artery calcium progression
has been proposed as a noninvasive method to follow atherosclerosis progression. Panel A (left) shows
calcified atherosclerosis in the left main (arrow) and left anterior descending (arrowhead) coronary arteries,
which progresses on a follow-up scan 2 years later (right). To differentiate calcium progression from
random error, attention must be placed on reproducing the scan procedure, including identical scanner
settings (in kilovolts and milliamperes) and eliminating coronary motion artifact, particularly with newer
methods of multidetector computed tomography scanning, which are more heart rate dependent for
reproducibility. Interscan reproducibility has been found to vary across trigger points within the R-R
interval, being optimal at lower R-R time points at faster heart rates. There is no fully accepted method for
the calculation of the calcium score progression rate. The most common approach is to calculate
progression rate as the percentage of increase per year relative to the baseline scan. This method is limited
by its dependence on the baseline score such that, for low coronary artery calcium scores, small absolute
changes in the calcium score lead to a large calculated difference in progression rate. B, Progression of
coronary artery calcium (CAC) is common. Typical coronary artery calcium progression rates are in the
range of 20% to 40% per year. The histogram shows the distribution of annual progression in the coronary
artery calcium score among middle-aged individuals with coronary artery calcium in Multi-Ethnic Study of
Atherosclerosis (MESA). Approximately 7% of middle-aged patients with a coronary artery calcium score of
0 will progress to show evidence of arterial calcification on an annual basis, with a range from 5% in 50 year
olds to more than 12% in 80-year-old individuals. C, Data on the relationship between coronary artery
calcium score progression and cardiovascular outcomes have suggested that event risk is high at
progression rates of 15% per year and higher. These data are relatively independent of the baseline calcium
score. Data from Raggi and colleagues indicated that significant calcium score progression is associated
with an 18-fold higher event risk. Data from other cohorts are needed to validate these findings, but the
paradigm of heightened coronary risk associated with atherosclerosis progression has been seen with
invasive coronary angiography, intravascular ultrasonography, and carotid intima-media thickness testing.
D, Data from several randomized clinical trials failed to show an effect of common risk interventions
(e.g., lipid lowering with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) on the calcium score
progression rate. These data suggest that progressive arterial calcification can indicate plaque progression,
but also can indicate healing of past subclinical plaque ruptures. Autopsy studies have shown areas of
heightened atherosclerosis calcification in association with sites of previous plaque ruptures that have
healed compared with other plaque morphologies such as erosions, acute ruptures, or vulnerable plaques.

CO MMENTS
Guidelines have not endorsed the clinical practice of
serial calcium scanning due to several factors. These
include the limited data to date on the relationship
between calcium score progression and outcomes, the
absence of therapies shown to slow coronary artery calcium progression, and the absence of clinical trial data
showing whether serial scanning alters management or
improves outcomes. The currently defined clinically
significant rate of progression is 15% or greater per year
relative to the baseline scan. The relationship between atherosclerosis and progression of its calcified

Case 7

component is complex, including some relationship to


risk factors and also to underlying plaque rupture events.
This may be in part the reason that coronary artery calcium is a stronger predictor of risk in middle-aged
patients than other plaque burden assessments such as
carotid intima media thickness. Specifically, coronary
artery calcium reflects not only atherosclerosis extent,
but is also an indicator of plaque activity in terms of previous subclinical plaque ruptures. More prospective
studies are needed on this topic. Until such data are
available, serial monitoring of coronary artery calcium
is not routinely recommended.

Aortic Wall Calcification

A 49-year-old perimenopausal woman presents for coronary artery calcium scanning.


Coronary calcium was present in all three coronary arteries. Incidentally, calcified
plaque was identified in the descending thoracic aorta (Fig. 7-7).

80

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

n Figure 7-7 A, Noncontrast computed tomography (CT) scan


showing a focus of calcification in the wall of the descending aorta
(arrow). This finding is consistent with large-vessel calcified
atherosclerosis, but can be seen in the absence of coronary calcification.
B, Noncontrast CT at a slice in the aortic arch showing calcification in
the aortic wall along the inferolateral region of the aortic arch. This is an
area of calcification normally seen in association with the site of the
ductus arteriosus and is a normal finding.

COMMENTS

SUGGESTED READINGS

The Pathobiological Determinants of Atherosclerosis in


Youth study identified unique risk factor determinants of
atherosclerosis in different vascular beds. In particular,
aortic atherosclerosis is more strongly related to hypertension, whereas coronary atherosclerosis is more
strongly associated with high-density lipoprotein and
nonhigh-density lipoprotein cholesterol concentration
and impaired glucose tolerance. The Framingham study
showed an overall two- to threefold increase in coronary
heart disease events associated with calcification of the
aortic knob on chest radiography that attenuated with
increasing age. In middle-aged participants of the
MESA, the prevalence of aortic wall calcification was
28% and was slightly more prevalent in women. Aortic
wall calcifications were most strongly associated with
hypertension and current smoking. Prognostically,
aortic wall calcification is a weak component of the overall coronary risk factor assessment, particularly in contrast or combination with coronary artery calcium
assessments.

Agatston AS, Janowitz WR, Hildner FJ, et al: Quantification of coronary artery calcium using ultrafast computed tomography, J Am Coll
Cardiol 15:827832, 1990.
Arad Y, Spadaro LA, Roth M, et al: Treatment of asymptomatic adults
with elevated coronary calcium scores with atorvastatin, vitamin C,
and vitamin E: The St. Francis Heart Study randomized clinical
trial, J Am Coll Cardiol 46:166172, 2005.
Bild DE, Detrano R, Peterson D, et al: Ethnic differences in coronary
calcification: The Multi-Ethnic Study of Atherosclerosis (MESA),
Circulation 111:13131320, 2005.
Brown ER, Kronmal RA, Bluemke DA, et al: Coronary calcium coverage score: Determination, correlates, and predictive accuracy in the
Multi-Ethnic Study of Atherosclerosis, Radiology 247:669675, 2008.
Budoff MJ, Achenbach S, Blumenthal RS, et al: Assessment of coronary artery disease by cardiac computed tomography: A scientific
statement from the American Heart Association Committee on Cardiovascular Imaging and Intervention, Council on Cardiovascular
Radiology and Intervention, and Committee on Cardiac Imaging,
Council on Clinical Cardiology, Circulation 114:17611791, 2006.
Burke AP, Taylor A, Farb A, et al: Coronary calcification: Insights from
sudden coronary death victims, Z Kardiol 89:S49S53, 2000.
Detrano R, Guerci AD, Carr JJ, et al: Coronary calcium as a predictor
of coronary events in four racial or ethnic groups, N Engl J Med
358:13361345, 2008.
Greenland P, Bonow RO, Brundage BH, et al: ACCF/AHA 2007 clinical expert consensus document on coronary artery calcium scoring
by computed tomography in global cardiovascular risk assessment

Chapter 7
and in evaluation of patients with chest pain: A report of the American College of Cardiology Foundation Clinical Expert Consensus
Task Force (ACCF/AHA Writing Committee to Update the 2000
Expert Consensus Document on Electron Beam Computed Tomography) developed in collaboration with the Society of Atherosclerosis Imaging and Prevention and the Society of Cardiovascular
Computed Tomography, J Am Coll Cardiol 49:378402, 2007.
Hendel RC, Patel MR, Kramer CM, et al: ACCF/ACR/SCCT/
SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for
cardiac computed tomography and cardiac magnetic resonance
imaging: A report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of
Cardiovascular Computed Tomography, Society for Cardiovascular
Magnetic Resonance, American Society of Nuclear Cardiology,
North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology, J Am Coll Cardiol 48:14751497, 2006.
Horiguchi J, Yamamoto H, Akiyama Y, et al: Coronary artery calcium
scoring using 16-MDCT and a retrospective ECG-gating reconstruction algorithm, AJR Am J Roentgenol 183:103108, 2004.
Kronmal RA, McClelland RL, Detrano R, et al: Risk factors for the
progression of coronary artery calcification in asymptomatic subjects: Results from the Multi-Ethnic Study of Atherosclerosis
(MESA), Circulation 115:27222730, 2007.

Detection of Calcified Atherosclerosis

81

Mao S, Budoff MJ, Bakhsheshi H, Liu SC: Improved reproducibility of


coronary artery calcium scoring by electron beam tomography with
a new electrocardiographic trigger method, Invest Radiol 36:363367,
2001.
McGill HC Jr, McMahan CA, Herderick EE, et al: Effects of coronary
heart disease risk factors on atherosclerosis of selected regions of the
aorta and right coronary artery. PDAY Research Group. Pathobiological Determinants of Atherosclerosis in Youth, Arterioscler Thromb
Vasc Biol 20:836845, 2000.
Raggi P, Callister TQ, Shaw LJ: Progression of coronary artery
calcium and risk of first myocardial infarction in patients receiving
cholesterol-lowering therapy, Arterioscler Thromb Vasc Biol
24:12721277, 2004.
Takasu J, Katz R, Nasir K, et al: Relationships of thoracic aortic wall
calcification to cardiovascular risk factors: The Multi-Ethnic Study
of Atherosclerosis (MESA), Am Heart J 155:765771, 2008.
Taylor AJ, Bindeman J, Feuerstein I, et al: Community-based provision
of statin and aspirin after the detection of coronary artery calcium
within a community-based screening cohort, J Am Coll Cardiol
51:13371341, 2008.
Witteman JC, Kannel WB, Wolf PA, et al: Aortic calcified plaques and
cardiovascular disease (the Framingham study), Am J Cardiol
66:10601064, 1990.

Chapter

Coronary CT Angiography:
The Patient with
Noncalcified Plaque
Joanne D. Schuijf and Jeroen J. Bax

KEY POINTS
l

In the general asymptomatic population, the finding of obstructive noncalcified plaque in


patients with zero calcium scores is rare and estimated at less than 1%. In symptomatic
patients, this percentage may be higher.

In some patients (e.g., those with acute coronary syndromes, diabetes), the coronary calcium score may underestimate total plaque burden and risk; contrast-enhanced computed
tomography (CT) angiography may provide more information than calcium scoring.

Noncalcified and mixed plaques on CT are more frequently observed in patients with acute
coronary syndromes and may represent earlier and more unstable stages of coronary artery
disease.

Quantification of plaque (e.g., degree of stenosis or volume) remains challenging and


requires optimal image quality.

Although good agreement exists between plaque characterization on CT and intravascular


ultrasonography, accurate differentiation of noncalcified tissue into fibrotic or fibrofatty
subtypes is currently not feasible.

82

Chapter 8

Case 1

Coronary CT Angiography: The Patient with Noncalcified Plaque

83

Patient with Diabetes Mellitus Type 2 and Noncalcified Plaque

A 54-year-old man with no history of coronary artery disease (CAD) presented with
unstable chest pain and negative myocardial injury biomarkers. Cardiovascular risk
factors were smoking and diabetes mellitus type 2. The patient was evaluated by
cardiac CT (Fig. 8-1).

n Figure 8-1 A, Curved multiplanar reconstruction of the left anterior descending coronary artery.
Despite a negative coronary calcium score, a significant lesion consisting of noncalcified tissue was
demonstrated in the proximal left anterior descending coronary artery at the bifurcation with the first
diagonal (arrows). B, Findings were confirmed by conventional coronary angiography (arrows).

CO MMENTS
The finding of obstructive noncalcified plaque in the general asymptomatic population of patients with zero calcium scores is rare and estimated at less than 1%. In
symptomatic patients, however, this percentage may be
higher. Several retrospective studies have further evaluated the presence of noncalcified plaque in relation to
clinical characteristics and presentation. In general,
patients with predominantly noncalcified plaque are
younger and the amount of mixed and calcified plaque
increases with age. In addition, the presence of noncalcified plaque seems to coincide with a higher prevalence of
coronary risk factors such as hypercholesterolemia and
diabetes, although variable results have been reported.

Case 2

Scholte and colleagues evaluated plaque characteristics


in 73 asymptomatic patients with diabetes and observed
that the majority of lesions were either noncalcified
(41%) or completely calcified (39%). When correlating
the presence of plaque with the coronary calcium score,
the authors observed that even in those with calcium
scores less than 10, atherosclerosis was present in 55%.
These observations may be in line with the prognostic
observations of Raggi and colleagues, who observed
higher event rates for each calcium score in patients with
diabetes compared with those without. Accordingly, calcium scoring may, in certain clinical scenarios, not fully
appreciate the risk due to a relatively higher proportion
of underlying noncalcified plaque burden.

Noncalcified Plaque with Spotty Calcifications in Acute Coronary


Syndrome

A 66-year-old man presented to the emergency department with suspected acute


coronary syndrome. Cardiovascular risk factors were smoking, diabetes mellitus type
2, and peripheral vascular disease. The electrocardiogram showed minimal ST
segment depression in V3, V4, and V5. Myocardial injury biomarkers were negative.
The CT evaluation of this patient is shown in Figure 8-2.

84

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

c
n Figure 8-2 A, Cardiac
computed tomography (CT)
(64 slice) showed the presence of
diffuse obstructive atherosclerosis.
Axial maximum intensity projection
(a) shows the presence of
noncalcified plaque with diffuse
spotty calcifications (mixed
plaques). Cross-sectional images
(b) show the presence of small
calcium deposits (arrow) as well as
considerable noncalcified tissue
(arrowheads). Orthogonal
multiplanar reconstructions (c)
show the presence of obstructive
coronary artery disease (CAD) due
to predominantly mixed plaques.
B, Comparison of plaque
characteristics on CT between
culprit lesions in patients
presenting with an acute coronary
syndrome and stable CAD. In
patients with acute coronary
syndrome, significantly more
lesions with a spotty calcification
pattern as well as low-density
lesions were observed. NCP,
noncalcified plaque; HU,
Hounsfield units. (Adapted from
Motoyama D, Kondo T, Sarai M,
et al: Multislice computed
tomographic characteristics of
coronary lesions in acute coronary
syndromes. J Am Coll Cardiol
50:319326, 2007.

A
120

ACS
Stable CAD

100100

Percentage

100

87

79

80

63
55

60
40
21
20

12

22

Positive NCP <30 HU 30 HU <NCP


Spotty
Large
Remodeling
<150 HU Calcification Calcification

COMMENTS
Consistent differences in plaque composition on CT have
been reported in retrospective comparisons of patients
with stable CAD and patients with suspected acute coronary syndrome. In several studies, a higher prevalence
of noncalcified and spotty calcifications (lesions containing noncalcified plaque and small calcified deposits) has
been observed on CT in patients with suspected acute
coronary syndrome. In contrast, extensive calcifications
seem to be more frequently present in patients with stable
CAD, a finding also shown with invasive techniques.
Accordingly, these observations suggest that the presence

Case 3

of predominantly large calcifications on CT may represent more advanced, relatively stabilized stages of CAD.
In contrast, a higher proportion of noncalcified tissue in
combination with smaller calcified deposits may be linked
to earlier and relatively unstable stages of disease and may
predict plaque vulnerability. Recent prognostic data
demonstrated that the presence of noncalcified plaque
was associated with an increased likelihood of cardiovascular events. Moreover, this information was shown to
be incremental to not only clinical characteristics but also
the presence of ischemia on myocardial perfusion imaging
as well as obstructive stenosis on CT.

Obstructive Coronary Artery Disease without Detectable


Calcium in a Patient with Suspected Acute Coronary Syndrome

A 43-year-old patient presented with new-onset chest pain during exercise.


Cardiovascular risk factors were smoking and a positive family history. Noninvasive
coronary angiography with CT (Fig. 8-3) showed diffuse noncalcified atherosclerosis
with significant lesions in the right coronary artery and distal left main coronary artery.

A
a

n Figure 8-3 A, Curved multiplanar reconstruction indicating a significant stenosis in the right
coronary artery. Cross-sectional images at the lesion site (14) show the presence of substantial
noncalcified plaque (arrows) resulting in luminal narrowing. Cross section 5 represents the distal reference
segment with considerably larger lumen. B, Computed tomography (CT) images of the left main and left
anterior descending coronary arteries. Curved multiplanar reconstruction (a) reveals an irregular and
obstructive lesion in the distal left main artery (arrow). Noncalcified atherosclerosis can be observed in the
proximal left anterior descending artery (arrowheads). Two orthogonal multiplanar reconstructions (b)
illustrate the left main lesion (arrows) in more detail. Finally, consecutive cross-sectional images (c) show
the presence of large noncalcified plaque burden resulting in significant luminal narrowing.
Continued

85

86

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

n Figure 8-3contd C, Conventional coronary angiogram confirming the presence of a significant


lesion in the right coronary artery (arrow). D, Conventional coronary angiogram confirming the presence of
a significant lesion in the distal left main artery (arrow).

COMMENTS
As a result of the relatively higher proportion of noncalcified plaque noted in patients with acute coronary syndrome, obstructive CAD in the absence of calcium may
occur more frequently in this population. Henneman
and colleagues recently observed that atherosclerosis
was present in 85% of patients presenting with acute

Case 4

coronary syndrome and no calcium. Moreover, obstructive CAD was identified in 39%, indicating that in this
patient population the absence of calcium may not reliably rule out CAD. Nevertheless, it remains important
to realize that in low-risk, stable patients, the observation of clinically relevant plaque burden in those with
zero coronary calcium scores is uncommon.

Pitfalls in the Detection and Evaluation of Noncalcified Plaque

Figure 8-4 shows calcified plaque in the left anterior descending coronary artery in
an obese patient (body mass index >35 kg/m2). The contrast-to-noise ratio is very

n Figure 8-4 In this image, the presence of calcified plaque in


the left anterior descending coronary artery (arrowheads) can be
recognized without any difficulties. However, the image clearly
has a poor contrast-to-noise ratio due to obesity (body mass index
>35 kg/m2). As a result, the lumen delineation is poor, rendering
it difficult to reliably establish the presence of noncalcified
plaque (region indicated by arrows).

Chapter 8

Coronary CT Angiography: The Patient with Noncalcified Plaque

87

poor, resulting in poor lumen delineation and making it difficult to reliably establish
the presence of noncalcified plaque (region indicated by arrows). This problem may
frequently be even more pronounced in distal coronary segments with smaller
luminal dimensions.

CO MMENTS
Reliable detection of plaque (and noncalcified plaque in
particular) can be challenging with CT. Using intravascular ultrasonography as the standard of reference, sensitivity and specificity to detect or exclude coronary
plaque of approximately 85% and approximately 90%,
respectively, have been reported using 16-slice CT.
However, these accuracies have been driven mainly by
the detection of calcified plaques, which are relatively
easy to detect. Detection of noncalcified plaques is more
difficult and seems to be slightly lower, in the range of
75% to 80%. Similarly, reported interobserver variability is slightly worse for the detection of noncalcified plaques compared with coronary plaque in general. Of
note, these studies were performed using 16-slice CT,
and substantially better results have been obtained using
the more advanced 64-slice systems. Image quality

Case 5

greatly influences the visualization of noncalcified


plaque, as illustrated in this case. In particular, noise
and motion artifacts can be easily mistaken for noncalcified plaque.
Further differentiation of noncalcified plaque configuration based on attenuation values remains challenging at
present. Although attenuation values are significantly
lower in lesions consisting mainly of fibrofatty tissue compared with fibrotic lesions, the overlap of attenuation
values between individual lesions is considerable. Moreover, attenuation values are highly dependent on factors
such as the amount of contrast, patient weight, and cardiac
output. As a result, it remains impossible to determine content for a single noncalcified lesion more precisely based on
attenuation values. Potentially, more detailed plaque characterization could be obtained by dedicated contrast agents
or the use of dual-energy imaging.

Automated Quantification of the Degree of Stenosis Using


Dedicated Software

A 59-year-old man presented with atypical chest pain and was evaluated with
320-slice CT (Fig. 8-5).
n Figure 8-5 A and B, Curved
multiplanar reconstructions of a
lesion in the proximal left anterior
descending coronary artery. An
eccentric, noncalcified plaque can be
observed (arrow). C, A straightened
multiplanar reconstruction is shown
using dedicated software (QAngioCT
1.1, Medis Medical Imaging Systems,
Leiden, The Netherlands). On a
corresponding cross-sectional image,
the lumen border is automatically
detected and delineated by a yellow
line (D). E, The straightened
multiplanar reconstruction with the
automatically detected lumen
borders in yellow and the expected
lumen borders based on normal
tapering of the vessel in red. F, The
graph displays the luminal
dimensions throughout the vessel
using the same colors. Similar to
quantitative coronary angiography,
the minimal lumen diameter is
detected and indicated by O.
Proximal and distal reference
diameters (indicated by P and D,
respectively) are then used to
calculate the degree of stenosis. In
this patient, the minimal lumen
diameter was 2.1 mm with a reference
lumen diameter of 4.3 mm, resulting
in a stenosis percentage of 52.8%.

88

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

COMMENTS
Reliable quantification of the degree of stenosis and plaque
volume remains a significant challenge. Due to the inferior
resolution of CTcompared with invasive coronary imaging
techniques, predominantly poor to moderate correlations
have been reported thus far. In addition, interobserver
variability of stenosis quantification is high, precluding
any clinical use at present. Nevertheless, noninvasive
assessment of plaque volume presents an interesting feature of CT because it potentially could be used to monitor
changes in plaque burden after anti-atherosclerotic medical therapy. Automated quantitative software may provide
more accurate and reproducible measurements. Also, software to provide information on plaque volume and total
plaque burden is currently under development.

SUMMARY AND F UTURE


PERSPECTIVES
The detection of noncalcified plaque presents an
intriguing and promising feature of cardiac CT.
Although it may be presumed that the CTcharacteristics
of lesions observed in patients presenting with acute coronary syndrome may be suggestive of plaque vulnerability, data on the prognostic value of CT, and the
observation of noncalcified plaque in particular, are
scarce. Accurate evaluation and quantification of plaque
volume are still hampered by the inferior resolution of
CT compared with invasive techniques. As a result,
accuracy and reproducibility of plaque detection and
quantification are still limited, as well as the ability to
further characterize the noncalcified plaque component
in more detail. Considering also the radiation dose associated with CT, screening with CT with the only purpose of detecting these noncalcified lesions is therefore
at present not recommended. Prospective trials are
needed on the potential of contrast-enhanced cardiac
CT angiography to provide prognostic information that
is incremental to standard risk stratification. Secondary
questions in such trials should address which features
as well as what extent of plaque seen on CT may be of
clinical relevance.

SUGGESTED READINGS
Achenbach S, Moselewski F, Ropers D, et al: Detection of calcified and
noncalcified coronary atherosclerotic plaque by contrast-enhanced,
submillimeter multidetector spiral computed tomography: A segment-based comparison with intravascular ultrasound, Circulation
109:1417, 2004.
Akram K, ODonnell RE, King S, et al: Influence of symptomatic status on the prevalence of obstructive coronary artery disease in
patients with zero calcium score, Atherosclerosis 203:533537, 2009.
Bamberg F, Dannemann N, Shapiro MD, et al: Association between
cardiovascular risk profiles and the presence and extent of different
types of coronary atherosclerotic plaque as detected by multidetector computed tomography, Arterioscler Thromb Vasc Biol
28:568574, 2008.
Beckman JA, Ganz J, Creager MA, et al: Relationship of clinical presentation and calcification of culprit coronary artery stenoses, Arterioscler Thromb Vasc Biol 21:16181622, 2001.

Burgstahler C, Reimann A, Beck T, et al: Influence of a lipid-lowering


therapy on calcified and noncalcified coronary plaques monitored by
multislice detector computed tomography: Results of the New Age
II Pilot Study, Invest Radiol 42:189195, 2007.
Burke AP, Weber DK, Kolodgie FD, et al: Pathophysiology of calcium
deposition in coronary arteries, Herz 26:239244, 2001.
Cademartiri F, Mollet NR, Runza G, et al: Influence of intracoronary
attenuation on coronary plaque measurements using multislice computed tomography: Observations in an ex vivo model of coronary
computed tomography angiography, Eur Radiol 15:14261431, 2005.
Ehara S, Kobayashi Y, Yoshiyama M, et al: Spotty calcification typifies
the culprit plaque in patients with acute myocardial infarction: An
intravascular ultrasound study, Circulation 110:34243429, 2004.
Ferencik M, Nieman K, Achenbach S: Noncalcified and calcified coronary plaque detection by contrast-enhanced multi-detector computed tomography: A study of interobserver agreement, J Am Coll
Cardiol 47:207209, 2006.
Hausleiter J, Meyer T, Hadamitzky M, et al: Prevalence of noncalcified
coronary plaques by 64-slice computed tomography in patients with
an intermediate risk for significant coronary artery disease, J Am Coll
Cardiol 48:312318, 2006.
Hendel RC, Patel MR, Kramer CM, et al: ACCF/ACR/SCCT/
SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for
cardiac computed tomography and cardiac magnetic resonance
imaging: A report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of
Cardiovascular Computed Tomography, Society for Cardiovascular
Magnetic Resonance, American Society of Nuclear Cardiology,
North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology, J Am Coll Cardiol 48:14751497, 2006.
Henneman MM, Schuijf JD, Pundziute G, et al: Noninvasive evaluation with multislice computed tomography in suspected acute coronary syndrome, J Am Coll Cardiol 52:216222, 2008.
Hyafil F, Cornily JC, Feig JE, et al: Noninvasive detection of macrophages using a nanoparticulate contrast agent for computed tomography, Nat Med 13:636641, 2007.
Leber AW, Becker A, Knez A, et al: Accuracy of 64-slice computed
tomography to classify and quantify plaque volumes in the proximal
coronary system: A comparative study using intravascular ultrasound, J Am Coll Cardiol 47:672677, 2006.
Leber AW, Knez A, Becker A, et al: Accuracy of multidetector spiral
computed tomography in identifying and differentiating the composition of coronary atherosclerotic plaques: A comparative study with
intracoronary ultrasound, J Am Coll Cardiol 43:12411247, 2004.
Leber AW, Knez A, von Ziegler F, et al: Quantification of
obstructive and nonobstructive coronary lesions by 64-slice computed tomography: A comparative study with quantitative coronary
angiography and intravascular ultrasound, J Am Coll Cardiol
46:147154, 2005.
Marquering HA, Dijkstra J, de Koning PJ, et al: Towards
quantitative analysis of coronary CTA, Int J Cardiovasc Imaging
21:7384, 2005.
Mintz GS, Pichard AD, Popma JJ, et al: Determinants and correlates
of target lesion calcium in coronary artery disease: A clinical, angiographic and intravascular ultrasound study, J Am Coll Cardiol
29:268274, 1997.
Mollet NR, Cademartiri F, Nieman K, et al: Noninvasive assessment of
coronary plaque burden using multislice computed tomography, Am
J Cardiol 95:11651169, 2005.
Motoyama S, Kondo T, Sarai M, et al: Multislice computed tomographic characteristics of coronary lesions in acute coronary syndromes, J Am Coll Cardiol 50:319326, 2007.
Pohle K, Achenbach S, MacNeill B, et al: Characterization of non-calcified coronary atherosclerotic plaque by multi-detector row CT:
Comparison to IVUS, Atherosclerosis 190:174180, 2007.
Raggi P, Shaw LJ, Berman DS, et al: Prognostic value of coronary
artery calcium screening in subjects with and without diabetes,
J Am Coll Cardiol 43:16631669, 2004.
Schmid M, Achenbach S, Ropers D, et al: Assessment of changes in
non-calcified atherosclerotic plaque volume in the left main and left
anterior descending coronary arteries over time by 64-slice computed tomography, Am J Cardiol 101:579584, 2008.

Chapter 8

Coronary CT Angiography: The Patient with Noncalcified Plaque

Scholte AJ, Schuijf JD, Kharagjitsingh AV, et al: Prevalence of coronary


artery disease and plaque morphology assessed by multi-slice computed tomography coronary angiography and calcium scoring in
asymptomatic patients with type 2 diabetes, Heart 94:290295, 2008.
Schuijf JD, Beck T, Burgstahler C, et al: Differences in plaque composition and distribution in stable coronary artery disease versus acute

89

coronary syndromes; non-invasive evaluation with multi-slice computed tomography, Acute Card Care 9:4853, 2007.
van Werkhoven JM, Schuijf JD, Gaemperli O, et al: Prognostic value
of multi-slice computed tomography and gated single photon emission computed tomography in patients with suspected coronary
artery disease, J Am Coll Cardiol 53:623632, 2009.

Chapter

The Post-Revascularization Patient


Matthew J. Budoff

KEY POINTS
l

Multidetector computed tomography (CT) provides a detailed anatomic assessment of


patients with a history of coronary artery bypass surgery or coronary stenting.

Smaller stent sizes and multiple stents limit the application of cardiac CT to the patient
after stent placement. In particular, the accuracy of CT is lower in stents less than
3.0 mm in diameter.

Multidetector CT bypass graft imaging is nearly 100% sensitive and specific for graft evaluation due to the absence of calcifications in the grafts, larger diameters, and lack of graft
motion.

Multidetector CT provides a road map for the location of the grafts (relative to the coronary arteries and sternum), atherosclerosis of the aorta, and simultaneous evaluation of
both mammary arteries in patients undergoing repeat cardiac surgical procedures.

Imaging of the native coronary arteries in patients with coronary bypass surgery can be
limited by motion artifacts, diffuse coronary artery disease, dense arterial calcifications,
and smaller diameters of the native coronary arteries.

90

Chapter 9

Case 1

The Post-Revascularization Patient

Stenting and Cardiac CT

A 66-year-old woman presented with atypical chest pain that began several years
after coronary artery stent placement. The original coronary stent procedure was
complicated by a coronary arterial dissection, which was treated by stenting. As a
result, the patient had a total of five stents in the right coronary artery. A coronary
CT angiogram was requested to evaluate stent patency and evaluate for the
development of new obstructive lesions (Fig. 9-1).

B1

B2
B

E
n Figure 9-1 For legend, see next page.

91

92

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

n Figure 9-1contd A, Volume-rendered image of the right coronary artery demonstrating multiple
stents (arrows) extending into the distal branch vessels. The central arterial lumen at the site of the
stent is not visible using volume-rendered images because this only portrays the outer walls. This imaging
technique is only useful to determine the position of the stents relative to the branch vessels and evaluate
for filling distal to the stents. B, Curved multiplanar reformation image demonstrating multiple stents.
This image provides more detail, and particularly for larger stents 3.0 mm and greater, the central lumen
can be clearly seen. The areas of stent overlap (arrow) and smaller, denser stents (arrowhead) cause more
imaging artifacts, which make interpretation more challenging. The proximal segment (B1) shows in-stent
restenosis of moderate severity, identified by the region of low attenuation. Usually it is difficult to
ascertain partial in-stent restenosis with cardiac computed tomography (CT), but this case is easier due to
the larger diameter of the proximal stent. The mid portion of the stent (B2) shows normal filling.
Evaluation of stents is facilitated by using wider display windows to better distinguish the differences in
attenuation values between metal and contrast. The lumens of stents (arrowhead) are easier to discern using
advanced imaging techniques (B). Use of typical imaging windows or maximum intensity projection
(C) makes interpretation of stent lumens difficult. C, Same case with typical imaging windows. The distal
stent (left, yellow arrow) is not well seen. By widening the imaging window, the stent lumen is better
visualized. Stent visualized by use of maximum intensity projection (right). D, By thickening the window,
the brightest parts of the stent are seen, making lumen visualization impossible. Although maximum
intensity projection imaging is an excellent technique for native coronary assessment, it is not useful in
stent evaluation. E, Moderate proximal coronary arterial stenosis (arrow) seen on the angiogram
corresponding to cardiac CT in-stent stenosis. (Images courtesy of Cardiovascular Medical Group, Beverly
Hills, CA.)

COMMENTS
The ability to visualize in-stent restenosis depends on
stent design and material, stent size, and scanner technology. Thus, further studies may prove that a certain
combination of stent type and scanner technology may
permit the detection of in-stent restenosis. Studies performed using 64-slice CT show a sensitivity for detection of in-stent restenosis of 83% to 92%. The most
common limitation to examining coronary stent patency
is stent size (smaller stent sizes are associated with lower

Case 2

accuracy rates). The most recent studies demonstrate


slightly higher diagnostic accuracy, but even with 64slice multidetector CT or higher, the stent size will
remain a significant limitation because of the limits of
spatial resolution. Tips to increase the ability to evaluate
within stents include eliminating the potential for coronary motion artifact, in some instances performing
reconstructions using sharper reconstruction filters,
and a variety of display parameters including wider
windows and black and white display inversion.

Bypass Grafting

A 69-year-old man with mild shortness of breath and a history of bypass surgery
(12 years earlier) was referred for coronary CT angiography after an exercise
test with myocardial perfusion scintigraphy showed an equivocal mild apical defect.
The purpose of the cardiac CT examination was to determine both bypass graft
patency and the status of the native coronary arteries (Fig. 9-2). This study was
performed with prospective gating; thus, the total radiation dose was only
5.6 millisieverts (mSv).

Chapter 9

The Post-Revascularization Patient

C
n Figure 9-2 A, Volume-rendered image demonstrating the multiple patent grafts with one graft with
moderate disease (white arrow). There is also a stent in the distal right coronary artery (yellow arrow).
The left internal mammary is well visualized (red arrows). Volume-rendered images are useful in graft cases
to provide an overview of the anatomy including the three-dimensional relationships between graft, the
sternum, and other mediastinal structures. B, The origins of the three vein grafts (yellow arrows) can easily
been seen on computed tomography angiography, providing a road map for identifying the origins of the
grafts when invasive angiography is subsequently necessary. C, Curved multiplanar image of the bypass
patient demonstrating the patent insertion of the left internal mammary artery (yellow arrow). Clips are
most common within the course of the internal mammary artery grafts. A careful, 360-degree evaluation
on multiplanar reformatted images is typically needed to clearly separate the arterial lumen from the clip
so that graft patency can be completely examined.

93

94

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 3

Coronary Bypass

A 62-year-old man with a mild abnormality on myocardial perfusion scintigraphy


(inferior ischemia versus diaphragmatic attenuation) was referred for CT
angiography. He had a history of coronary artery bypass surgery 9 years previously.
The purpose of the examination was to determine both graft patency and the status
of the native coronary arteries (Fig. 9-3).

C
n Figure 9-3 Severe coronary artery disease was identified at the insertion of the right coronary artery
graft. A, Volume-rendered image demonstrating the 100% obstruction at the insertion of the right
coronary artery graft (yellow arrow). B and C, The patient underwent invasive angiography and subsequent
stenting of the graft. The invasive angiogram demonstrated 100% obstruction of the distal segment of
the right coronary artery graft (yellow arrow).

Chapter 9

CO MMENTS
Numerous studies have shown that cardiac CT angiography permits assessment of coronary bypass graft
occlusion and patency with high accuracy. Due to their
larger diameter, relative immobility, and less frequent
calcifications, diagnostic accuracy is higher with bypass
grafts than native coronary arteries. A recent meta-analysis by Hamon and colleagues reported a sensitivity of
97.6% and a specificity of 96.7% for stenosis detection
compared with invasive angiography, with even better
results for the detection of total occlusions. The 2006
multisociety appropriateness criteria identified cardiac
CT before repeat coronary artery bypass as an appropriate cardiac CT indication. A particular strength is
the determination of the spatial relationships between
coronary grafts and anticipated surgical dissection
planes, which could pose a hazard during the surgical
approach. The cardiac surgeon gains information on
the location of the grafts to the sternum, the health of
the unused conduits (such as the right internal mammary), and the size and amount of disease in the aorta
(more aortic atherosclerosis is associated with a ninefold
increased risk of stroke at the time of surgery, especially
if conduits entering the aorta itself are used). Also, after
CT angiography, the cardiologist has a better understanding of the location and number of grafts, and the
nonselective nature of the contrast injection allows for

The Post-Revascularization Patient

95

more complete assessment of the grafts and aorta. The


disadvantages of CT angiography in this setting include
lower accuracy for native arteries in bypass patients
(primarily due to dense calcifications) and higher radiation exposure due to longer vertical (z axis) coverage
required.

SUGGESTED READINGS
Cademartiri F, Mollet N, Lemos PA, et al: Usefulness of multislice
computed tomographic coronary angiography to assess in-stent
restenosis, Am J Cardiol 96:799802, 2005.
Hamon M, Lepage O, Malaguitti P, et al: Diagnostic performance of
16- and 64-section spiral CT for coronary artery bypass graft assessment: Meta-analysis, Radiology 247:679686, 2008.
Hendel RC, Patel MR, Kramer CM, et al: ACCF/ACR/SCCT/
SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for
cardiac computed tomography and cardiac magnetic resonance
imaging: A report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of
Cardiovascular Computed Tomography, Society for Cardiovascular
Magnetic Resonance, American Society of Nuclear Cardiology,
North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology, J Am Coll Cardiol 48:14751497, 2006.
Mahnken AH, Buecker A, Wildberger JE, et al: Coronary artery stents
in multislice computed tomography: In vitro artifact evaluation,
Invest Radiol 39:2733, 2004.
Mahnken AH, Seyfarth T, Flohr T, et al: Flat-panel detector computed
tomography for the assessment of coronary artery stents: Phantom
study in comparison with 16-slice spiral computed tomography,
Invest Radiol 40:813, 2005.

Chapter

10

Advanced Vessel Analysis


Harvey S. Hecht

KEY POINTS
l

Advanced vessel analysis is an intravascular ultrasonography (IVUS) equivalent.

Measurement of the minimal luminal area (MLA) by computed tomography angiography


(CTA) is more important than minimal luminal diameter and percentage of diameter
stenosis.

Diffuse segmental narrowing is better detected by CTA advanced vessel analysis than catheter angiography.

Advanced vessel analysis can identify features consistent with vulnerable plaques.

Advanced vessel analysis can aid in stent planning.

The path to the target lesion can be characterized by advanced vessel analysis and may
affect therapeutic options.

96

Chapter 10

Advanced Vessel Analysis

97

Case 1
A 56-year-old woman presented to the emergency department after a 1-hour episode
of moderate substernal burning. Quantitative analysis of coronary CTA showed 50%
to 75% right coronary artery stenosis (Fig. 10-1).

n Figure 10-1 Computed tomography angiography curved


multiplanar reconstruction revealed severe mid right coronary artery
(RCA) stenosis (A) not apparent on subsequent catheter angiography
(B). Tomographic intravascular analysis (D) of the straightened
multiplanar reconstruction (C) demonstrated significantly reduced
minimal luminal area of 3.5 mm2, confirmed by intravascular
ultrasonography (D) and followed by percutaneous coronary
intervention of the affected area. MLA, minimal luminal
area. (From Hecht HS: Applications of multislice coronary computed
tomography to percutaneous coronary intervention: How did we ever
do without it? Catheter Cardiovasc Interv 71:490503, 2008, with
permission.)

CO MMENTS
Advanced vessel analysis is predicated on the derivation
of cross-sectional images from straightened multiplanar
reconstructions and by tomographic intravascular analysis generation of MLA and plaque analysis similar to
IVUS. Tomographic intravascular analysis of the lesion
revealed an MLA of 3.5 mm2, fulfilling the IVUS criterion of less than 4.0 mm2 for a significant proximal vessel stenosis. The patient was admitted from the
emergency department and underwent conventional
coronary angiography, which revealed only 25% to
50% right coronary artery stenosis. IVUS was performed to resolve the discrepancy between the CTA
and catheterization findings. The MLA was 3.2 mm2,

confirming the CTA results, and percutaneous coronary


intervention (PCI) was performed.
Invasive coronary angiography is subject to limitations that are overcome by advanced vessel analysis.
The insufficient sampling error inherent in the limited
number of acquisitions in the catheterization laboratory
makes it extremely unlikely that a stenosis is captured in
its narrowest dimension. Even more importantly, the
percentage of diameter stenosis based on the minimal
lumen diameter has limitations in its physiologic significance except in the rare perfectly concentric lesion.
Rather, it is the MLA that determines flow, a parameter
easily obtained by advanced vessel analysis, as illustrated
in this case. Excellent correlation with IVUS has been
established.

98

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 2
A 55-year-old man experienced recurrent chest pain 1 year after placement of a
drug-eluting stent in the proximal left anterior descending artery (Fig. 10-2).

n Figure 10-2 Computed tomography angiography curved


multiplanar reconstruction of the left anterior descending artery
(LAD) (A) revealed significant diffuse narrowing from the left
anterior descending artery ostium to the stent, with only slight
narrowing evident on the corresponding catheter angiography (B).
Tomographic intravascular analysis (D) of the straightened
multiplanar reconstruction (C) demonstrated significantly reduced
minimal luminal area (MLA) of 2.9 mm2, confirmed by intravascular
ultrasonography (D), and followed by percutaneous coronary
intervention. (From Hecht HS: Applications of multislice coronary
computed tomography to percutaneous coronary intervention: How
did we ever do without it? Catheter Cardiovasc Interv 71:490503, 2008,
with permission.)

COMMENTS
The CT angiogram revealed diffuse narrowing of the left
anterior descending artery from the ostium to the patent
stent. The absence of a reference area precludes percentage
of diameter stenosis calculation; the left main artery proximally and the stent distally cannot be used for reference.
However, the tomographic intravascular analysis revealed
a significantly reduced MLA of 2.9 mm2. The patient
underwent catheter angiography, which did not reveal significant disease; the IVUS confirmed the CTA findings,
and a coronary stent was placed in the arterial segment.

One of the major lessons of IVUS is the misleading


benign angiographic appearance of diffusely narrowed
segments that may contain substantial plaque burden.
A significant focal stenosis may be absent, irrespective
of the angiographic view. The luminal appearance on
the CT angiogram will be equally devoid of a significant
stenosis, but, as in this instance confirmed with IVUS,
tomographic intravascular analysis enables identification
of the true severity of the disease by permitting calculation of the MLA.

Case 3
A 60-year-old woman without known coronary artery disease presented with 6
months of progressive exertional dyspnea without chest pain (Fig. 10-3).

Chapter 10

Advanced Vessel Analysis

99

Lumen Area
EEL Area
Plaque Area
% Plaque Burden
Fibrous Area
Fibro-Fatty Area
Dense Calcium Area
Necrotic Core Area

5.8 mm2
16.2 mm2
10.3 mm2
64%
4.8 mm2
0.7 mm2
0.9 mm2
0.7 mm2

58%
9%
13%
10%

Lumen Area
EEL Area
Plaque Area
% Plaque Burden
Fibrous Area
Fibro-Fatty Area
Dense Calcium Area
Necrotic Core Area

2.6 mm2
11.8 mm2
9.3 mm2
78%
4.4 mm2
0.3 mm2
0.6 mm2
1.1 mm2

68%
5%
10%
17%

n Figure 10-3 A, Computed tomography angiography curved multiplanar reconstruction demonstrated significant left main artery (LM) and
ostial left circumflex artery (LCX) disease less apparent on the subsequent catheter angiography. Tomographic intravascular analysis of the
straightened multiplanar reconstruction (B) demonstrated significantly reduced left main artery minimal luminal area (MLA) of 5.2 mm2 and
2.9 mm2 for the left circumflex artery, confirmed by intravascular ultrasonography. Virtual histology revealed predominantly fibrous plaque
in the left main artery (C) and left circumflex artery (D), with a slightly increased necrotic core (17%) in the left circumflex artery. EEL, external
elastic lamina. (From Hecht HS: Applications of multislice coronary computed tomography to percutaneous coronary intervention: How did we
ever do without it? Catheter Cardiovasc Interv 71:490503, 2008, with permission.)

CO MMENTS
Both left main and left circumflex artery disease was clearly
apparent on the CT angiogram, and the significantly
reduced MLAs were demonstrable despite the presence
of extensive calcified plaque in the bifurcation area. Catheter angiography revealed the left circumflex artery disease,
but left main artery stenosis was less apparent. The CTA
findings of significant distal left main (<6 mm2) and ostial
circumflex (<4 mm2) artery disease were confirmed by
IVUS, and coronary artery bypass grafting was performed.

The measurement of MLA is complicated by the


presence of extensive calcified plaque; a hypodense
interface of noncalcified plaque between the contrast
and calcified plaque is required for MLA determination.
Without this interface, the true borders of the calcified
plaque and lumen cannot be differentiated. In addition,
extremely dense calcified plaque (>1000 Hounsfield
units [HU]) may shadow adjacent contrast and result
in an erroneously decreased MLA.

Case 4
A 56-year-old man underwent implantation of a drug-eluting stent in the proximal left
anterior descending artery for symptomatic coronary artery disease identified with CTA.
Four months later, he presented with the recurrence of classic angina, and CTA was
repeated (Fig. 10-4).

100

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

n Figure 10-4 A, Initial computed tomography


angiography (CTA) revealed severe ostial stenosis (left)
that was angiographically inapparent (right). B,
Tomographic intravascular analysis yielded an ostial
minimal luminal area (MLA) of 2.7 mm2 (left), leading
to intravascular ultrasound evaluation, which
confirmed the tomographic intravascular analysis
findings (right). Ostial stenting was performed, with
angiographic improvement (C) and increase of the
minimal luminal area from 2.8 to 8.3 mm2 (D). EG,
Follow-up CTA performed to evaluate the recurrence of
angina demonstrated patency of the left anterior
descending artery study but a new critical left main
stenosis (E, left), confirmed by catheter angiography (E,
right); coronary artery bypass grafting was performed.
Comparison of the left main artery and ostial left
anterior descending artery tomographic intravascular
analysis (F) from the two evaluations documented a
decrease in the left main artery minimal luminal area
from 6.7 to 2.6 mm2 and patency of the ostial left
anterior descending artery stent (G). (From Hecht HS:
Applications of multislice coronary computed
tomography to percutaneous coronary intervention:
How did we ever do without it? Catheter Cardiovasc Interv
71:490503, 2008, with permission.)

Chapter 10

CO MMENTS

101

most likely cause of the new left main coronary artery


lesion.
Trauma from the PCI undoubtedly led to the left
main artery disease just as similar insult to the ostial left
anterior descending artery during the first stent implantation was the likely cause of the ostial disease. The
operator was aware of the moderate distal left main
artery disease noted on the CT angiogram before the
procedure (see Fig. 10-4G, left) and confirmed by IVUS,
but the small-caliber distal vessel prompted PCI rather
than coronary artery bypass grafting. CTA advanced
vessel analysis provides the operator with an IVUS view
of the vessel en route to the target lesion, revealing disease that may not be obvious on coronary angiography
and potentially altering the choice of procedure.

The initial CT angiogram revealed significant ostial left


anterior descending artery disease that was angiographically inapparent but indicated through calculation
of the MLA. As with case 2, there was no reference
segment on either the CT angiogram or invasive angiogram, but IVUS confirmed the tomographic intravascular analysis findings, and an ostial left anterior
descending artery stent was implanted, accompanied by
an increase in area from 2.8 mm2 to 8.3 mm2 and disappearance of symptoms.
The recurrence of angina within 6 months of stent
placement is most suggestive of in-stent restenosis. In
this case, however, trauma to the ostial vessel immediately proximal to the stent during implantation was the

Case 5
A 61-year-old man presented with substernal discomfort described as a burning
sensation that occurred at rest (Fig. 10-5).

n Figure 10-5 Computed


tomography angiography
revealed severe proximal right
coronary artery (RCA) stenosis
(A) (arrow), confirmed by
catheter angiography (B)
(arrow). Tomographic
intravascular analysis (D) of the
straightened multiplanar
reconstruction (C)
demonstrated critically reduced
minimal luminal area (MLA)
(2.0 mm2) and a large, lowdensity ( 34 Hounsfield units)
lipid-laden plaque adjacent to
the lumen, consistent with a
thin cap fibroatheroma.
Percutaneous coronary
intervention was
performed. (From Hecht HS:
Applications of multislice
coronary computed tomography
to percutaneous coronary
intervention: How did we ever
do without it? Catheter
Cardiovasc Interv 71:490503,
2008, with permission.)

Advanced Vessel Analysis

102

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

COMMENTS
The severe proximal right coronary artery stenosis was
angiographically apparent. However, the large lipid pool
adjacent to the lumen, characterized by the negative
Hounsfield units was not. It represents the CTA equivalent of the thin cap fibroatheroma, which is widely
believed to represent the vulnerable plaque. In this case,
the severe stenosis, with an MLA of 2.0 mm2, mandated

PCI irrespective of the thin cap fibroatheroma. Nonobstructive plaques with a thin cap fibroatheroma are currently candidates for aggressive medical treatment and
will remain so until evidence of the beneficial effect of
PCI in this setting is demonstrated. Positive remodeling,
which is associated with vulnerability, may also be readily identified by advanced vessel analysis measurement of
the external elastic membrane.

Case 6
An asymptomatic 71-year-old man with peripheral vascular disease underwent
coronary CTA for preoperative risk evaluation (Fig. 10-6).

COMMENTS
The discrepancy between CTA and catheter angiography, presumably reflecting the insufficient sampling
error implicit in the limited number of acquisitions in
the catheterization laboratory, was resolved by IVUS.
Both stenoses were associated with a reduced MLA,
and PCI was performed. The use of CTA for preoperative evaluation is an alternative to stress testing. The

goal of identifying significant triple vessel and left main


artery disease is more easily accomplished by CTA
because nuclear stress testing fails to identify 40% of
patients with triple vessel disease and 15% of those
with left main artery disease. A thin cap fibroatheroma
is also present, as shown by the necrotic core on the
color-encoded image correlating to the Hounsfield unit
values.

Case 7
An asymptomatic 33-year-old man with a strong family history of premature coronary
artery disease underwent CTA for risk evaluation (Fig. 10-7). The coronary calcium
score was 0.

COMMENTS
Because the patient was asymptomatic and there was no
obstructive disease, PCI was not indicated. However, aggressive medical therapy was mandated despite the 0 coronary
calcium score. The presence of ruptured plaques is associated with increased cardiovascular risk. The identification
of asymptomatic plaque rupture by CTA is in a preliminary
stage and is predicated on the Hounsfield unit measurements on the advanced vessel analysis. Values of the extraluminal density from 75% to 100% of the luminal contrast
are consistent with plaque rupture. Calcified plaque with
densities in the same range cannot be excluded unless a

noncontrast coronary calcium scan has been performed


and reveals no calcified plaque at that site. Although the
absence of calcified coronary plaque is generally associated
with an excellent prognosis, high-risk young patients,
defined by a family history of premature coronary disease,
may escape detection without CTA because there may be
considerable noncalcified plaque without an associated calcified component. Consequently, the use of CTA has been
proposed in this asymptomatic, high-risk population for risk
stratification. The earliest age for screening this group is not
established; the age at onset of premature coronary disease
in their first-degree relatives may be used as a guide.

Chapter 10

n Figure 10-6 Computed tomography


angiography revealed significant ostial and
proximal left anterior descending artery
disease (A), which was less impressive on
catheter angiography (B, arrows).
Tomographic intravascular analysis of the
straightened multiplanar reconstruction (C)
revealed significant equally decreased
minimal luminal area (MLA) at both sites
(upper left and right), confirmed by
intravascular ultrasonography (lower left and
right). In the proximal left anterior
descending artery (upper left), a moderatesized low-density ( 42 Hounsfield units)
lipid-laden plaque was noted, consistent
with a thin cap fibroatheroma. Virtual
histology of the proximal left anterior
descending artery lesion (D) revealed a large
necrotic core (23% of total plaque volume),
confirming the presence of a thin cap
fibroatheroma. EEL, external elastic
lamina. (From Hecht HS: Applications of
multislice coronary computed tomography
to percutaneous coronary intervention: How
did we ever do without it? Catheter Cardiovasc
Interv 71:490503, 2008, with permission.)

Lumen Area
EEL Area
Plaque Area
% Plaque Burden
Fibrous Area
Fibro-Fatty Area
Dense Calcium Area
Necrotic Core Area

3.5 mm2
13.3 mm2
5.3 mm2
74%
3.7 mm2
1.1 mm2
0.2 mm2
1.5 mm2

57%
17%
3%
23%

Advanced Vessel Analysis

103

104

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

D
n Figure 10-7 Curved multiplanar reconstruction of the left anterior descending artery revealed the
absence of calcified plaque and two extraluminal densities (B). Tomographic intravascular analysis of the
straightened multiplanar reconstruction (C) demonstrated Hounsfield units (HU) of the densities to be
similar to contrast (D), consistent with extravasation of contrast from ruptured noncalcified
plaques. (From Hecht HS: Applications of multislice coronary computed tomography to percutaneous
coronary intervention: How did we ever do without it? Catheter Cardiovasc Interv 71:490503, 2008, with
permission.)

Case 8
A 62-year-old man with atypical chest pain underwent CTA (Fig. 10-8).

COMMENTS
The 4.8 mm2 MLA of the ostial first obtuse marginal
branch stenosis did not meet criteria for PCI. The large
thin cap fibroatheroma, with a low attenuation value
suggestive of increased lipid content, suggested a vulnerable plaque but did not warrant catheter intervention in
the absence of a hemodynamically significant stenosis on
both the initial and follow-up scans. The ability of CTA
to track serial arterial changes has not been well documented; there are inherent problems in quantifying
plaque volume that currently preclude its use in

determining the effects of drug therapy on plaque size


and character. These problems include the lower spatial
resolution compared with IVUS (350 vs. 100150 mm),
the effect of adjacent structures on the densities of the
plaque components through partial volume effects and
shadowing, and the confounding effect of the calcified
component of plaque. Nonetheless, future technical
advancements in CT including improved spatial resolution and dual-energy acquisitions may enable serial
scanning for plaque volume.

Chapter 10

n Figure 10-8 Computed tomography angiography (CTA) (A) demonstrated a moderately severe ostial
first obtuse marginal (OM1) stenosis (arrow) that was not apparent on catheter angiography.
Tomographic intravascular analysis of the straightened multiplanar reconstruction (B) revealed a large
low-density ( 19 to 52 HU) plaque adjacent to the lumen, consistent with a thin cap fibroatheroma.
However, the minimal luminal area (MLA) was adequate (4.8 mm2), and percutaneous coronary
intervention was not performed. Six months later, chest pain recurred and CTA revealed no change in
the plaque characteristics or minimal luminal area (C). Aggressive medical therapy was
continued. (From Hecht HS: Applications of multislice coronary computed tomography to
percutaneous coronary intervention: How did we ever do without it? Catheter Cardiovasc Interv
71:490503, 2008, with permission.)

Advanced Vessel Analysis

105

106

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 9
A 66-year-old woman presented with increasing angina. She underwent a CTA study
(Fig. 10-9).

n Figure 10-9 A, Subtotal


left anterior descending artery
occlusion (arrow) was noted on
the computed tomography
angiogram (left) and on the
catheter angiogram (right).
B, The proximal and distal
stent landing zones, 23.6 mm
apart, were chosen on the
straightened multiplanar
reconstruction. Mean luminal
diameters for the landing zones
were determined by
tomographic intravascular
analysis of the external elastic
membrane (EEM) to be 4.4 and
3.4 mm, respectively (C).
Percutaneous coronary
intervention was performed
using a 25  3.5-mm stent,
with post-inflation of the
proximal segment to 4.5 mm to
achieve full apposition. (From
Hecht HS: Applications of
multislice coronary computed
tomography to percutaneous
coronary intervention: How did
we ever do without it? Catheter
Cardiovasc Interv 71:490503,
2008, with permission.)

COMMENTS
The proximal and distal landing zone determination of
longitudinal sizing can be chosen by the operator after
deciding the extent of atherosclerosis that should be
covered, similar to stent sizing by IVUS. Axial sizing is
accomplished by measuring the mean diameter of the
external elastic membrane at the proximal and distal

landing zones. The importance of accurate stent sizing


has been demonstrated by the increased incidence of target lesion revascularization and adverse clinical events
associated with geographic miss. Coronary CTA is an
excellent substitute for IVUS for stent sizing and eliminates the qualitative assessments that characterize the
use of catheter angiography.

Chapter 10

Case 10
A 64-year-old man presented with chest pain after bypass surgery (Fig. 10-10).

n Figure 10-10 Catheter


angiography (A) suggested a
pseudoaneurysm followed by
severe stenosis in a vein graft to
the marginal branch.
Percutaneous coronary
intervention was considered,
but CTA curved multiplanar
reconstruction (B) revealed
straightforward aneurysmal
dilation rather than a
pseudoaneurysm. Quantitative
measurements of the presumed
stenosis yielded 55% and 61%,
respectively, using proximal
and distal reference points and
avoiding the aneurysmal
segment. Cross-sectional
analysis of the straightened
multiplanar reconstruction (C)
using mean rather than
minimum diameters revealed
the stenosis measurements to
be 33% and 45%, respectively,
with more than adequate
minimal luminal area (MLA).
Medical therapy was
pursued. (From Hecht HS,
Jelnin V, Roubin GS:
Indications for multidetector
computed tomographic
coronary angiography after
catheter-based coronary
angiography. J Invasive Cardiol
20:16, 2008, with permission.)

Advanced Vessel Analysis

107

108

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

COMMENTS
Venous grafts may be particularly difficult to evaluate
because ectasia, which develops at variable rates over
time; determination of the normal reference segment
for accurate determination of the percentage of diameter
stenosis can be impossible. Moreover, as this case
demonstrates, the mean luminal diameter will differ substantially from the minimal luminal diameter in propor-

tion to the degree of eccentricity. Ultimately, the MLA,


which is the determinant of flow, was more than adequate. The ability of the advanced vessel analysis to
avoid overlap of portions of the same artery or of multiple vessels clarifies structural issues and clearly demonstrates the aneurysmal rather than a pseudoaneurysmal
graft.

Case 11
A 78-year-old man developed stable angina, and a nuclear stress testing revealed mild
apical ischemia (Fig. 10-11).

n Figure 10-11 Left main


stenosis (50%) was noted on the
curved multiplanar
reconstruction (A, arrow) and
on the catheter angiogram
(B, arrow). Tomographic
intravascular analysis (D) of the
straightened multiplanar
reconstruction (C)
demonstrated severe left main
stenosis with a minimal
luminal area (MLA) of 3.2 mm2.
The predominant plaque type
was noncalcified (<130
Hounsfield units [HU]),
between the lumen (460 HU)
and the calcified component
(364 HU). These findings were
confirmed by the
corresponding intravascular
ultrasonography (E).

COMMENTS
The severity of the left main artery stenosis was not
appreciated without the advanced vessel analysis demonstration of a markedly decreased MLA of 3.4 mm2. The
predominantly noncalcified plaque is readily demonstrated by Hounsfield unit measurement. The ability to
measure MLA is dependent on the low-density interface
between the calcified component and the lumen contrast. Typically a gradient of 150 to 200 HU between
the contrast and the low-density interface is required

to ensure accurate border detection for MLA


measurement.
The CTA-guided PCI paradigm (Fig. 10-12) is based
on the principles elucidated in cases 1 to 11. CTA performed in patients selected according to appropriate criteria can provide important data as the first step in
patient management, as an alternative to stress testing.
Benign CTA diameter and area measurements triage
the patient for medical management. Patients with
severe disease, defined as more than 75% stenosis, progress directly to catheter angiography. These patients are

Chapter 10

Advanced Vessel Analysis

109

CTA
n Figure 10-12 Computed
tomography angiography (CTA)
guided percutaneous coronary
intervention (PCI) paradigm. MLA,
minimal luminal area; LM, left
main artery; prox, proximal;
V, vessel; IVUS, intravascular
ultrasonography; FFR, fractional
flow reserve; CABG, coronary
artery bypass grafting.
(From Hecht HS, Jelnin V, Roubin
GS: Indications for multidetector
computed tomographic coronary
angiography after catheter-based
coronary angiography. J Invasive
Cardiol 20:16, 2008, with
permission.)

Stenosis <50% and/or


MLA >6 mm2 LM
>4 mm2 prox V

Stenosis 50%75% and


MLA <6 mm2 LM
<4 mm2 prox V
<3 mm2 mid V

Stenosis >75% LM
or prox/mid V

Selective Angiography
Medical
Treatment
Significant
Stenosis Absent

Significant
Stenosis Present

IVUS/FFR
IVUS
<6 mm2 LM
<4 mm2 prox V
<3 mm2 mid V
or FFR <0.75

IVUS
>6 mm2 LM
>4 mm2 prox V
>3 mm2 mid V
or FFR >0.75

PCI/CABG depending on
clinical/anatomic factors

* Consider stress test depending on clinical factors

relatively few in number because quantitative CTA


excludes positively remodeled reference areas and avoids
the overestimation of qualitative assessment of lesion
severity. Similarly, more than 75% stenoses are infrequently noted on catheter angiography when quantitative analysis, rather than visual estimation, is used.
Stenoses from 50% to 75% that fulfill the IVUS
MLA criteria derived from the tomographic intravascular analysis may be evaluated by stress testing to determine their functional significance; a positive test result
will lead to catheter angiography and a negative test
result to medical management. Fifty percent to 75% stenoses that do not fulfill the IVUS MLA criteria do not
warrant further evaluation or intervention.
Demonstration of significant disease by catheter
angiography will lead to PCI. If significant stenosis is
not angiographically apparent, IVUS or measurement
of fractional flow reserve should be performed, with
subsequent PCI or bypass surgery depending on the
result. In this large patient subset, the ultimate decision
is based on the CTA-guided IVUS or fractional flow
reserve and not simply on the CTA alone. This CTAguided PCI paradigm is dependent on the ability of each
laboratory to document the accuracy of their MLA measurements by IVUS correlations.

SUGGESTED READINGS
Achenbach S, Moselewski F, Ropers D, et al: Detection of calcified and
noncalcified coronary atherosclerotic plaque by contrast enhanced,
submillimeter multidetector spiral computed tomography: A segment-based comparison with intravascular ultrasound, Circulation
109:1417, 2004.

Achenbach S, Ropers D, Hoffmann U, et al: Assessment of coronary


remodeling in stenotic and nonstenotic coronary atherosclerotic
lesions by multidetector spiral computed tomography, J Am Coll
Cardiol 43:842847, 2004.
Bech GJW, Bruyne BD, Pijls NHJ, et al: Fractional flow reserve to
determine the appropriateness of angioplasty in moderate coronary
stenosis. A randomized trial, Circulation 103:29282934, 2001.
Caussin C, Larchez C, Ghostine S, et al: Comparison of coronary minimal lumen area quantification by sixty-four-slice computed tomography versus intravascular ultrasound for intermediate stenosis, Am J
Cardiol 98:871876, 2006.
Caussin C, Ohanessian A, Ghostine S, et al: Characterization of
vulnerable nonstenotic plaque with 16-slice computed tomography
compared with intravascular ultrasound, Am J Cardiol 94:99104,
2004.
Caussin C, Ohanessian A, Lancelin B, et al: Coronary plaque burden
detected by multislice computed tomography after acute myocardial
infarction with near-normal coronary arteries by angiography, Am J
Cardiol 92:849852, 2003.
Christou MAC, Siontisa GCM, Katritsis DG, et al: Meta-analysis of
fractional flow reserve versus quantitative coronary angiography
and noninvasive imaging for evaluation of myocardial ischemia,
Am J Cardiol 99:450456, 2007.
Hausleiter J, Meyer T, Hadamitzky M, et al: Prevalence of noncalcified
coronary plaques by 64-slice computed tomography in patients with
an intermediate risk for significant coronary artery disease, J Am Coll
Cardiol 48:312318, 2006.
Hecht HS: Applications of multislice coronary computed tomography
to percutaneous coronary intervention: How did we ever do without
it?, Catheter Cardiovasc Interv 71:490503, 2008.
Hecht HS, Roubin G: Usefulness of computed tomographic angiography guided percutaneous coronary intervention, Am J Cardiol
99:871875, 2007.
Kang X, Berman DS, de Yang L, et al: Diagnostic accuracy of gated
myocardial perfusion SPECT for detection of left main coronary
artery disease, J Am Coll Cardiol 176A, 2007.
Leber AW, Becker A, Knez A, et al: Accuracy of 64-slice computed
tomography to classify and quantify plaque volumes in the proximal
coronary system. A comparative study using intravascular ultrasound, J Am Coll Cardiol 47:672677, 2006.
Leber AW, Knez A, Becker A, et al: Accuracy of multidetector
spiral computed tomography in identifying and differentiating the

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composition of coronary atherosclerotic plaques: A comparative


study with intracoronary ultrasound, J Am Coll Cardiol 43:
12411247, 2004.
Lima RSL, Watson DD, Goode AR, et al: Incremental value of combined perfusion and function over perfusion alone by gated SPECT
myocardial perfusion imaging for detection of severe three-vessel
coronary artery disease, J Am Coll Cardiol 42:6470, 2003.
Moselewski F, Ropers D, Pohle K, et al: Measurement of crosssectional coronary atherosclerotic plaque and vessel areas by 16-slice
multi-detector CT: comparison to IVUS, Am J Cardiol 94:
12941297, 2004.
Nishioka T, Amanullah AM, Luo H, et al: Clinical validation of intravascular ultrasound imaging for assessment of coronary stenosis
severity. Comparison with stress myocardial perfusion imaging,
J Am Coll Cardiol 33:18701878, 1999.
Poon M, Rubin GD, Achenbach SA, et al: Consensus update on the
appropriate usage of cardiac computed tomographic angiography, J
Invasive Cardiol 19:484490, 2007.

Ragosta M, Bishop AH, Lipson LC, et al: Comparison between angiography and fractional flow reserve versus single-photon emission
computed tomographic myocardial perfusion imaging for determining lesion significance in patients with multivessel coronary disease,
Am J Cardiol 99:896902, 2007.
Takagi A, Tsurumi Y, Ishii Y, et al: Clinical potential of intravascular
ultrasound for physiological assessment of coronary stenosis relationship between quantitative ultrasound tomography and pressure-derived fractional flow reserve, Circulation 100:250255, 1999.
Virmani R, Kolodgie FD, Burke AP, et al: Lessons from sudden
coronary death: A comprehensive morphological classification
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von Birgelen C, Klinkhart W, Mintz GS, et al: Plaque distribution and
vascular remodeling of ruptured and nonruptured coronary plaques
in the same vessel: An intravascular ultrasound study in vivo, J Am
Coll Cardiol 37:18641870, 2001.

Chapter

11

Applications of PET-CT and


SPECT-CT
Marcelo F. Di Carli

KEY POINTS
l

The integration of nuclear medicine cameras with multidetector computed tomography


(CT) scanners (e.g., positron emission tomography [PET]-CT and single-photon emission
CT [SPECT-CT]) provides a unique opportunity to delineate cardiac and vascular
anatomic abnormalities and their physiologic consequences in a single setting.

One of the most basic uses of CT in hybrid imaging devices (e.g., PET-CT and SPECT-CT)
is for patient positioning and correction of the inhomogeneity of the scintigraphic data
caused by overlapping soft tissue (so-called attenuation correction).

A significant proportion of patients (50%) with normal myocardial perfusion studies


have evidence of subclinical atherosclerosis (sometimes extensive) revealed by CT. The
prognostic assessment provided by the CT calcium score and PET are complementary.

Myocardial perfusion imaging provides valuable clinical information regarding the physiologic significance of anatomic stenoses for identification of patients in need of potential
revascularization because approximately one third of intermediate coronary lesions on
coronary CT angiography are associated with abnormal myocardial perfusion.

Extensive coronary artery disease on coronary CT angiography in the setting of a normal


myocardial perfusion study may indicate the presence of balanced ischemia.

111

112

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 1
A 55-year-old man with a history of dyslipidemia and hypertension was referred for
evaluation of atypical chest pain. The patient underwent rest and stress technetium99msestamibi myocardial perfusion imaging using a hybrid SPECT-CT system
fitted with a six-slice multidetector CT scanner (Figs. 11-1 and 11-2).

MPI SPECT Nonattenuation Corrected

MPI SPECT Attenuation Corrected

rest SA
stress SA
rest SA
stress SA

rest HLA
stress HLA
rest VLA
stress VLA
n Figure 11-1 Use of computed tomography (CT) for attenuation correction of myocardial perfusion images. Left, The images (without
attenuation correction) show a fixed perfusion defect throughout the inferior wall. Right, The images (after CT-based attenuation correction)
show homogeneous perfusion throughout the left ventricle and complete resolution of the inferior wall defect, indicating that it was an
attenuation artifact. HLA, horizontal long axis; MPI, myocardial perfusion image; SA, short axis; SPECT, single-photon emission computed
tomography; VLA, vertical long axis.

COMMENTS
The integration of nuclear medicine cameras with multidetector CT scanners (e.g., PET-CT and SPECTCT) provides a unique opportunity to delineate cardiac
and vascular anatomic abnormalities and their physiologic consequences in a single setting. For the evaluation
of the patient with known or suspected coronary artery
disease (CAD), it allows detection and quantification of
the burden of the extent of calcified and noncalcified
plaques (coronary artery calcium and coronary angiography), quantification of vascular reactivity and endothelial health, identification of flow-limiting coronary
stenoses, and assessment of myocardial viability. Consequently, by revealing the burden of anatomic CAD and
its physiologic significance, hybrid imaging can provide
unique information that may improve noninvasive diagnosis, risk assessment, and management of CAD. In
addition, by integrating the detailed anatomic information from CT with the high sensitivity of radionuclide
imaging to evaluate targeted molecular and cellular

abnormalities, hybrid imaging may play a key role in


shaping the future of molecular diagnostics and
therapeutics.
One of the most basic uses of CT in hybrid imaging
devices (e.g., PET-CT and SPECT-CT) is for patient
positioning and correction of the inhomogeneity of the
scintigraphic data caused by overlapping soft tissue (socalled attenuation correction). Unlike CT for calcium
scoring or coronary angiography, acquisition parameters
for CT-based transmission imaging vary with the configuration of the CT scanner (e.g., 8, 16, 64 multidetector CT) and clinical protocol. However, the general scan
settings for CT transmission imaging adhere to the following principles: (1) a slow gantry rotation speed (e.g.,
1 second per revolution), combined with a relatively
high pitch (e.g., 0.50.6:1), (2) nongated scan, (3) a high
tube potential (e.g., 140 peak tube voltage measured in
kilovolts [kVp]) and a low tube current (1020 mA),
and (4) a CT acquisition obtained during tidal expiration
breath hold or shallow breathing.

Chapter 11

Applications of PET-CT and SPECT-CT

rest SA
stress SA
rest SA
stress SA

rest VLA
stress VLA

rest HLA
stress HLA

A
rest SA
stress SA
rest SA
stress SA

rest VLA
stress VLA

rest HLA

stress HLA

n Figure 11-2 Common computed tomography (CT)based attenuation correction artifacts. A, Left,
Corresponding rest and stress myocardial perfusion images obtained with rubidium 82 and positron
emission tomography, which are displayed in conventional short-axis (SA), vertical long-axis (VLA), and
horizontal long-axis (HLA) slices of the left ventricle (LV). These perfusion images demonstrate a severe
perfusion deficit involving the anterolateral and lateral LV walls (arrows), showing complete reversibility at
rest. This finding suggests moderate ischemia in the left circumflex and/or diagonal coronary territory.
Right, The quality of the registration between the stress perfusion data and its corresponding CT
transmission image. This image fusion demonstrates an obvious misalignment (arrows) between the two
data sets, such that the anterolateral wall of the LV on the rubidium images overlaps with the left lung
field. Because the lungs have a low-attenuation coefficient (i.e., air), the rubidium images are
undercorrected in the anterolateral wall compared with the rest of the LV, resulting in a regional perfusion
defect. Because this misalignment was not present at rest (images not shown), the resulting perfusion
defects were reversible. B, Repeat reconstruction of the perfusion images after proper alignment of the
perfusion and CT transmission images. There is complete resolution of the regional perfusion defect,
indicating that this was an artifact caused by incorrect attenuation correction. This misalignment between
the perfusion and transmission images is generally caused by the different breathing patterns that often
occur during the acquisition of the two independent data sets. Proper quality control is crucial before
interpretation of the attenuation-corrected myocardial perfusion images.

113

114

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 2
Two middle-aged men (patients A and B) presented with atypical chest pain and an
intermediate likelihood of CAD based on age, gender, symptoms, and risk factor
profile (Figs. 11-3 and 11-4).

Myocardial Perfusion

Coronary Artery Calcium

rest SA
stress SA
rest SA
stress SA

rest VLA
stress VLA
rest HLA
stress HLA

rest SA
stress SA
rest SA
stress SA
rest VLA
stress VLA
rest HLA
stress HLA
n Figure 11-3 Complementary information between coronary artery calcium and myocardial perfusion
imaging. Myocardial perfusion imaging shows normal regional myocardial perfusion in each case,
suggesting no evidence of flow-limiting coronary artery disease (CAD). Each patient also underwent non
contrast-gated computed tomography (CT). In patient A (top), the Agatston calcium score is zero,
suggesting a low burden of atherosclerosis. In patient B (bottom), there is extensive calcified coronary plaque
burden with a calcium score greater than 1000. This apparent discrepancy is not unexpected because the
myocardial perfusion imaging method is designed and targeted at the identification of flow-limiting
stenoses and lacks the sensitivity to delineate the extent of subclinical atherosclerosis. HLA, horizontal long
axis; SA, short axis; VLA, vertical long axis.

Chapter 11

Applications of PET-CT and SPECT-CT

115

Freedom from death or MI

Serious events by CAC score, nonischemic patients


1.0
0.95
0.90
CAC <1000
CAC 1000

0.85
P < .001
0.80
0

100

200
300
Days to event

400

500

Freedom from death or MI

Serious events by CAC score, ischemic patients


1.0
0.95
0.90
0.85
P < 0.001
0.80
0

100

200
300
Days to event

400

500

n Figure 11-4 Interaction between ischemia, coronary artery calcium (CAC), and clinical outcomes. This
figure illustrates the risk-adjusted survival probabilities of consecutive patients referred for clinical testing
for suspected coronary artery disease, stratified by the absence (top) or presence (bottom) of ischemia on
positron emission tomography (PET) and the magnitude of CAC by computed tomography (CT). With
increasing levels of CAC, cardiac event rates increase in stepwise fashion among patients with and without
evidence of ischemia on PET myocardial perfusion imaging (MPI). The adjusted survival free of major
adverse events in patients with normal PET MPI and no CAC was substantially better than in those with
normal PET and a CAC score of 1000 or higher. Likewise, the annualized event rate in patients with
ischemia on PET MPI and no CAC was better than among those with ischemia and a CAC score of 1000 or
higher. MI, myocardial infarction. (From Schenker MP, Dorbala S, Hong ECT, et al: Interrelation of
coronary calcification, myocardial ischemia, and outcomes in patients with intermediate likelihood of
coronary artery disease: A combined positron emission tomography/computed tomography study.
Circulation 117:16931700, 2008, with permission.)

CO MMENTS
The potential to acquire and quantify rest and stress
myocardial perfusion and CT information from a single
study using hybrid imaging opens the door to expanding
the prognostic potential of stress perfusion imaging.
Recent data suggest that quantification of coronary
artery calcium scores at the time of stress myocardial
perfusion/PET imaging using a hybrid approach can
enhance risk predictions in patients with suspected
CAD. One of the unique strengths of hybrid imaging
is the fact that it is possible to obtain anatomic data
depicting the quantitative burden of atherosclerosis and
relevant functional information that defines the physiologic consequences of the anatomic burden of disease

in the same setting. Recent evidence comparing the


results of cardiac CT and myocardial perfusion imaging with both SPECT and PET suggest that a significant
proportion of patients (50%) with normal myocardial
perfusion studies have evidence of subclinical atherosclerosis (sometimes extensive) by CT. These two examples
demonstrate potentially complementary information
between the anatomic and functional data sets from
hybrid imaging. Incorporating information regarding
the anatomic extent of atherosclerosis in conventional
models using myocardial perfusion alone may serve as a
more rational basis for personalizing the intensity and
goals of medical therapy in a more cost-effective manner.

116

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 3
A 54-year-old man with medical history of controlled diabetes and hypertension was
referred for evaluation of new-onset exertional shortness of breath and atypical
chest pain (Figs. 11-5 and 11-6).

Baseline LVEF
53%

Peak Dobutamine LVEF


68%

Endo+Epi

Endo+Epi
Ant

Ant

Sep

Sep

Apex
Apex
Inf

Inf

ED

ED

n Figure 11-5 Integrated positron emission tomography (PET)/


computed tomography angiography (CTA) study for the diagnosis and
management of coronary artery disease. A, The CTA images
demonstrate a noncalcified plaque (arrow) in the proximal left anterior
descending artery (LAD) with 50% to 70% stenosis (top left), confirmed
on the cross-sectional views of the vessel (right). Ant, anterior; ED, end
diastolic; Endo Epi, endocardial plus epicardial; Inf, inferior; LCX,
left circumflex artery; LM, left main artery; LVEF, left ventricular
ejection fraction; RCA, right carotid artery. B, Rest and peak
dobutamine stress myocardial perfusion PET study (lower left)
demonstrate near-normal myocardial perfusion. In addition, LV
ejection fraction was normal at rest and demonstrated a normal
increase during peak dobutamine stress, with normal systolic motion
of the anterior wall. (From Di Carli MF, Hachamovitch R: New
technology for noninvasive evaluation of coronary artery disease.
Circulation 115:14641480, 2007, with permission.)

Chapter 11

PPV

Applications of PET-CT and SPECT-CT

NPV

100

100

91

117

91

94

88

80
60
44
40

29

31

39

32

20
0
n Figure 11-6 Summary results of different studies showing the relationship between coronary stenosis
by computed tomography coronary angiography (CTCA) and ischemia. This graph illustrates the frequency
of inducible ischemia by myocardial perfusion imaging, as determined by single-photon emission
tomography or positron emission tomography, in territories supplied by stenosis of 50% or more as
assessed by CTCA. These data confirm the consistently high negative predictive value (NPV) of CTCA for
excluding disease. However, the data also highlight the known limitations of anatomic approaches such as
CTCA to define physiologic significance. PPV, positive predictive value.

CO MMENTS
Coronary vessel motion as well as high-density objects
such as calcium and stent struts limit the ability of CT
to accurately delineate the degree of coronary luminal
narrowing. This can lead to overestimation of stenosis
severity and an overall reduction in test specificity and
positive predictive value. From a clinical perspective, a
normal CT angiogram is helpful because it effectively
excludes the presence of obstructive CAD and the need
for further testing, it defines a low clinical risk, and
makes management decisions straightforward. Because
of its limited accuracy to define stenosis severity and
predict flow-limiting disease, abnormal CT angiography
results are more problematic to interpret and to use as
the basis for defining the potential need of invasive coronary angiography and myocardial revascularization.

The stress perfusion information provides valuable clinical information regarding the physiologic significance
of anatomic stenoses for identification of patients in
need of potential revascularization. Reasons for this
include that the use of the percentage of diameter stenosis is only a modest descriptor of coronary resistance
because it does not incorporate other lesion characteristics (e.g., length, shape, eccentricity). Similarly, stenoses
in series may greatly affect the impedance to blood flow
and modulate downstream ischemic burden. Vasomotor
tone and coronary collateral flow, both of which are
known to affect myocardial perfusion, are not assessed
by simple measures of stenosis severity. Myocardial
perfusion imaging provides a simple and accurate
integrated measure of the effect of all these parameters
on coronary resistance and tissue perfusion.

118

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 4
A 66-year-old man with a history of hypertension was referred for evaluation of
angina (Fig. 11-7).

A
Stress

Baseline LVEF
54%
Endo-Epi

Peak stress LVEF


63%
Endo-Epi

Ant

Ant

Rest

Sep

Sep

Stress

Apex

Apex
Rest
Inf

Inf
ED

Gate 1

B
n Figure 11-7 Integrated positron emission tomography (PET)/computed tomography (CT)
angiography study for the diagnosis and management of coronary artery disease (CAD). A, Coronary CT
angiogram shows extensive calcified plaque burden throughout the coronary arteries. The left anterior
descending artery (LAD) and left circumflex artery (LCX) show severe calcified plaque in their proximal
and mid segments. The dominant right coronary artery (RCA) shows multiple calcified plaques, with a
severe, predominantly noncalcified plaque in its mid segment. RPL, right posterolateral branch. B, Rest and
peak adenosine stress myocardial perfusion PET demonstrates only moderate ischemia in the inferior wall
(arrowheads). In addition, the left ventricular ejection fraction (LVEF) was normal at rest and demonstrated
a normal increase during peak stress, effectively excluding the presence of flow-limiting three-vessel CAD.
Ant, anterior; Endo-Epi, endocardial-epicardial; Inf, inferior, Sep, septum. (From Di Carli MF,
Hachamovitch R: New technology for noninvasive evaluation of coronary artery disease. Circulation
115:14641480, 2007, with permission.)

COMMENTS
This case illustrates how stress perfusion imaging can
help delineate the ischemic burden and guide management decisions. In the integrated strategy (PET-CT or
SPECT-CT), the importance of stress perfusion

imaging is its ability to quantify the extent of jeopardized myocardium and identify which patients may
benefit from revascularization, that is, differentiating
high-risk patients with extensive scarring versus those
with extensive ischemia.

Case 5
A 68-year-old man with a history of dyslipidemia and diabetes and atypical chest pain
was referred for preoperative risk evaluation before high-risk noncardiac surgery
(Fig. 11-8).

Chapter 11

Applications of PET-CT and SPECT-CT

119

rest SA

stress SA

rest SA

stress SA

rest VLA
n Figure 11-8 Integrated
positron emission tomography/
computed tomography (CT)
angiography study for the
diagnosis and management of
coronary artery disease. A, Rest
and adenosine-stress rubidium
82 myocardial perfusion imaging
demonstrates normal regional
myocardial perfusion. The gated
images demonstrated a decrease in
left ventricular ejection fraction
from peak stress to rest (63% to
50%). B, CT coronary angiography
images demonstrate a significant,
heavily calcified stenosis of the left
main artery (LM). Subsequent
coronary angiography confirmed
the presence of severe left main
artery stenosis, and the patient
underwent surgical
revascularization. LV, left ventricle;
RA, right atrium.

stress VLA

rest HLA
stress HLA

CO MMENTS
This case illustrates the complementary aspects of CT
coronary angiography and myocardial perfusion imaging. One of the known limitations of myocardial perfusion imaging (both SPECT and PET) is the fact that,

although the relative assessment of myocardial perfusion


is a sensitive means for diagnosing or ruling out the
presence of obstructive CAD, it frequently underestimates the extent of disease and occasionally it can miss
severe CAD.

120

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 6
A 34-year-old man with hypertrophic cardiomyopathy and exertional shortness of
breath as well as decreased exercise tolerance underwent a sequential stress
myocardial perfusion study and coronary CT angiography (Figs. 11-9 and 11-10).

99mTc Myocardial Perfusion SPECT


Vert Long Axis (Sep>Lat)

Aorta

LAD

RCA
Left
Atrium

B
n Figure 11-9 Integrated single-photon emission computed tomography (SPECT)/computed tomography (CT) coronary angiography
study for the diagnosis and management coronary artery disease. A, Selected multiplanar reformats from the coronary CT angiogram show
no evidence of atherosclerosis. There was evidence of a long myocardial bridge along the mid left anterior descending artery (LAD) (arrows,
top right). The patient performed a Bruce protocol (10.6 METS [metabolic equivalents]) for 9 minutes, 11 seconds. His heart rate increased
from 58 to 120 beats per minute (65% of the age-predicted heart rate). The blood pressure response to exercise was blunted (94/70 to 100/60
mm Hg at peak exercise). He developed typical chest pain at peak stress that resolved 4 minutes into recovery. Technetium-99m (99mTc)
myocardial perfusion SPECT images demonstrate a large and severe perfusion defect throughout the anterior and apical walls, showing
moderate reversibility. LM, left main artery; Sep, septum; Lat, lateral; Vert, vertical. B, The three-dimensionally rendered, coregistered stress
perfusion and CT coronary angiography images demonstrate that the large and severe perfusion defect seen on the SPECT images tracks
with the location of the myocardial bridge in the left anterior descending artery. RCA, right coronary artery.

Chapter 11

LM

Applications of PET-CT and SPECT-CT

LCX

Diag

RCA

LAD

RCA

121

Diag: 2 mL/min/g
LAD: 3 mL/min/g

RCA: 4 mL/min/g

n Figure 11-10 Integrated positron emission tomography (PET)/computed tomography (CT) angiography study for the diagnosis and
management of coronary artery disease. The three-dimensionally rendered, coregistered images of myocardial perfusion assessed by PET and
CT coronary angiography illustrate the ability of the PET/CT approach to provide a quantitative measure of atherosclerotic burden and
coronary vasodilator function (in mL/min/g of myocardium). Diag, diagonal coronary territory; LAD, left anterior descending artery; LCX,
left circumflex artery; LM, left main artery; RCA, right coronary artery. (Courtesy of Dr. Juhani Knuuti, Turku PET Center, Turku, Finland.)

CO MMENTS
PETs unique ability to enable noninvasive measurements of myocardial blood flow and coronary vasodilator reserve offers a unique combination approach to
improve detection of multivessel CAD and assess the
consequences of coronary risk factors on endothelial
and microvascular function.

SUGGESTED READINGS
Anagnostopoulos C, Almonacid A, El Fakhri G, et al: Quantitative
relationship between coronary vasodilator reserve assessed by (82)
Rb PET imaging and coronary artery stenosis severity, Eur J Nucl
Med Mol Imaging 35:15931601, 2008.
Beanlands RS, Muzik O, Melon P, et al: Noninvasive quantification of
regional myocardial flow reserve in patients with coronary atherosclerosis using nitrogen-13 ammonia positron emission tomography:
Determination of extent of altered vascular reactivity, J Am Coll
Cardiol 26:14651475, 1995.
Di Carli M, Czernin J, Hoh CK, et al: Relation among stenosis severity, myocardial blood flow, and flow reserve in patients with coronary artery disease, Circulation 91:19441951, 1995.
Di Carli MF, Dorbala S, Curillova Z, et al: Relationship between CT
coronary angiography and stress perfusion imaging in patients with
suspected ischemic heart disease assessed by integrated PET-CT
imaging, J Nucl Cardiol 14:799809, 2007.
Di Carli MF, Hachamovitch R: New technology for noninvasive evaluation of coronary artery disease, Circulation 115:14641480, 2007.

Gould KL: Identifying and measuring severity of coronary artery stenosis: Quantitative coronary arteriography and positron emission
tomography, Circulation 78:237245, 1988.
Leber AW, Becker A, Knez A, et al: Accuracy of 64-slice computed
tomography to classify and quantify plaque volumes in the proximal
coronary system: A comparative study using intravascular ultrasound, J Am Coll Cardiol 47:672677, 2006.
Parkash R, deKemp RA, Ruddy TD, et al: Potential utility of rubidium
82 PET quantification in patients with 3-vessel coronary artery disease, J Nucl Cardiol 11:440449, 2004.
Raff GL, Gallagher MJ, ONeill WW, Goldstein JA: Diagnostic accuracy of noninvasive coronary angiography using 64-slice spiral computed tomography, J Am Coll Cardiol 46:552557, 2005.
Schenker MP, Dorbala S, Hong ECT, et al: Interrelation of coronary
calcification, myocardial ischemia, and outcomes in patients with
intermediate likelihood of coronary artery disease: A combined positron emission tomography/computed tomography study, Circulation
117:16931700, 2008.
Schuijf JD, Wijns W, Jukema JW, et al: Relationship between noninvasive coronary angiography with multi-slice computed tomography
and myocardial perfusion imaging, J Am Coll Cardiol 48:
25082514, 2006.
Uren NG, Melin JA, De Bruyne B, et al: Relation between myocardial
blood flow and the severity of coronary artery stenosis, N Engl J Med
330:17821788, 1994.
Yoshinaga K, Katoh C, Noriyasu K, et al: Reduction of coronary flow
reserve in areas with and without ischemia on stress perfusion imaging in patients with coronary artery disease: A study using oxygen
15-labeled water PET, J Nucl Cardiol 10:275283, 2003.

Chapter

12

The Left Ventricle


Andreas H. Mahnken

KEY POINTS
l

Cardiac computed tomography (CT) allows accurate assessment of global and regional left
ventricular function at rest. It provides precise measurements of left ventricular morphology, such as chamber dimensions.

If coronary CT angiography has been performed, additional assessment of left ventricular


morphology and function may obviate the need for further cross-sectional imaging, including magnetic resonance imaging (MRI) and echocardiography at rest. Evaluation of stress
and rest myocardial perfusion with CT is an investigational technique.

Electrocardiographically (ECG)-gated CT is suited for the categorical diagnosis of cardiomyopathies, including dilated (ischemic vs. nonischemic) and hypertrophic cardiomyopathies.

Cardiac CT findings in uncommon myocardial diseases contribute to the final diagnosis


and therapeutic decision making.

For a comprehensive assessment of cardiac CT examinations, the entire data set must be
evaluated, independent of the clinical question. Because information on myocardial morphology and function may alter therapy, systematic data analysis in cardiac CT includes
the coronary arteries, ventricular morphology, global and regional function, as well as
the assessment of extracardiac structures.

122

Chapter 12

Case 1

The Left Ventricle

123

Normal Left Ventricular Function

A 49-year-old patient with intermittent episodes of chest pain was referred for exclusion
of coronary artery disease. He had no history of cardiac disease. Cardiovascular risk
factors included prehypertension and smoking. The calculated 10-year Framingham risk
score was 15%. Coronary calcifications and obstructive coronary artery disease were
excluded by coronary dual-source CTangiography (Fig. 12-1).

58

57

56

58

15
57

16
56

15

16

60

60

17

17

58

58

18

18

57

57

19

19

60

60

20

20

58

21
58

21

B
n Figure 12-1 A, Systematic data analysis in cardiac computed tomography (CT) goes beyond imaging of the coronary arteries to include
assessment of left ventricular morphology and function. Although assessment of the coronary arteries is mostly done using mid or enddiastolic images, functional imaging requires multiphase image reconstruction comprising systole and diastole. The number of phases
multiplied by the temporal resolution should equal or exceed the length of the R-R interval. For most heart rates, reconstruction of 20 phases
is sufficient (bottom). If fewer phases are used, gaps may occur, especially at low heart rates (top). B, Assessment of left ventricular function is
done from 5- to 8-mm thickness standardized double-oblique images in the views shown. A potential workflow for computing these imaging
planes from CT data is indicated by the arrows. The dotted line indicates the relationship between the two-chamber view and four-chamber
view. The dashed line indicates the relationship between short-axis view and the four-chamber view and two-chamber view. Three-chamber
view images are computed along a plane through the left ventricular outflow tract.
Continued

D
n Figure 12-1contd C, The left ventricular myocardium can be divided in segments for description of regional wall motion. Most
commonly, a 17-segment model of the left ventricle is used. Using the imaging planes described in B, all myocardial segments are visualized
from two perpendicular perspectives. D, For quantification of the global ventricular function, end-systolic and end-diastolic short-axis
images are selected from multiphase image reconstructions. The increased image noise on systolic images is due to an electrocardiographydependent tube-current modulation, with an 80% decreased radiation exposure during systole, but the image is generally adequate for
interpretation purposes because the images are reconstructed in thick section.
Continued

124

Chapter 12

The Left Ventricle

125

E
61.0
60.0

(%)

59.0
EF (Phantom)
EF (83 msec)
EF (165 msec)

58.0
57.0
56.0
55.0

40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140


bpm

Vol (ml)

97
91
85
79
73
67
61
55
49
43
37

0 10 20 30 40 50 60 70 80 90 100
Time (%)

n Figure 12-1contd E, Left ventricular volumes and mass are typically calculated using Simpsons method, i.e., summing the crosssectional area multiplied with the section thickness from the base to the apex. The apex is defined as the section with the ventricular
cavity visible throughout the entire cardiac cycle, whereas the most basal section is identified by the presence of at least 50% myocardium
throughout the entire R-R interval. Trabeculae and papillary muscles are commonly included with the blood pool because this approach is
known to improve data reproducibility. Myocardial mass is determined from subtracting volumes as calculated using epicardial (black line)
and endocardial (red line) borders. For correct delineation of the interventricular septum, a sufficient contrast in the right ventricle must be
achieved. F, Accurate quantification of the global left ventricular function depends on heart rate and temporal resolution of the CT scanner
used. From phantom data and clinical data, it has been shown that, up to a heart rate of approximately 65 beats per minute (bpm), a
temporal resolution of 165 msec is sufficiently accurate. Reconstruction of the R-R cycle by intervals of 5% (20 reconstructions per R-R
interval) yields optimal results for accurate determination of the end-systolic and end-diastolic positions. In patients with higher heart rates,
a better temporal resolution is needed as shown in a dynamic phantom. G, From multiphase short-axis images, systolic and diastolic wall
thickness and wall thickening can be computed after manual or (semi-) automated detection of the epi- and endocardial borders. This
information can be plotted in a so-called bulls-eye plot (left). The same information may be used to compute time-volume curves, which may
be helpful for the detailed assessment of abnormalities of myocardial function (right).

126

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

COMMENTS
Systematic data analysis, including the consequent
assessment of myocardial morphology and function at
rest, is feasible with a single comprehensive CT examination. If performed consequently cardiac CT will

Case 2

provide valuable insights into each patients cardiovascular status. With 64-slice and dual-source CT, the functional assessment of cardiac CT data is sufficiently
accurate for a reliable assessment of all functional
parameters.

Ischemic Heart Failure

A 68-year-old patient presented with progressive symptoms of heart failure. He had a


history of recurrent non-ST segment elevation myocardial infarction and multivessel
coronary artery bypass surgery (right coronary artery, diagonal and marginal
branches, left anterior descending artery) 7 years ago. He was diagnosed with
ischemic heart failure. He had a severely compromised state of health with chronic
obstructive lung disease and pulmonary hypertension. Because he refused another
invasive coronary angiographic procedure, he was referred for cardiac CT for
assessment of coronary bypass graft patency (Fig. 12-2).

B
n Figure 12-2 A, Three-dimensional volume-rendered image computed from retrospectively electrocardiographically gated dual-source
coronary computed tomography angiography proved patency of three venous bypass grafts (arrows). The left internal mammary artery to the left
anterior descending artery graft is also patent (arrowheads). B, Multiplanar reformations along the short (left) and long (middle and right) axes of
the left ventricle. There is marked thinning of the myocardium, particularly in the basal and mid posterior segments (arrows). Hypodense areas in
subendocardial myocardium are suggestive of regions of hypoperfusion (white arrows). The left ventricle is dilated with a left ventricular
end-diastolic diameter of 6.1 cm (dotted arrow). In combination with the coronary state, this information is indicative of poor prognosis in
patients with ischemic heart failure.
Continued

Chapter 12

The Left Ventricle

127

C
n Figure 12-2contd C, Analysis of left ventricular function showed a markedly reduced ejection fraction of 27% and revealed a globally
reduced wall motion. Reduced wall thickening is nicely illustrated by a bulls-eye plot with dark (blue) areas representing regions of severely
impaired wall thickening. D, In analogy to magnetic resonance imaging, wall motion can be analyzed semiquantitatively. Regular wall motion is
considered normal (1); reduced wall motion is either classified hypokinetic, i.e., reduced systolic wall thickening (2), or akinetic, i.e., absent
regional wall thickening (3). A systolic outward movement of a left ventricular wall segment is categorized dyskinetic (4).

CO MMENTS
CT is known to permit a reliable assessment of the coronary arteries in ischemic heart failure with an accuracy,
sensitivity, specificity, positive predictive value, and negative predictive value of 95%, 90%, 97%, 93%, and
95%, respectively. The clinical value of cardiac CT is
further expanded by the ability of CT to also evaluate

Case 3

the morphology and functional state of the myocardium.


Cardiac CT correlates well with MRI and echocardiography for the measurement of the ejection fraction and
for measurement of left ventricular inner end-diastolic
diameter (r 0.77). The temporal resolution of cardiac
CT also permits analysis of regional wall motion.

Ischemic Cardiomyopathy (Negative Coronary Calcium Score)

A 67-year-old woman presented with newly developed dyspnea. Except for mild
arterial hypertension and a moderately elevated body mass index (28 kg/m2), she had
no cardiovascular risk factors. The calculated 10-year Framingham risk score was
11%. She was referred for further diagnostic workup (Fig. 12-3).

CO MMENTS
Ischemic cardiomyopathy is defined as a state of
impaired contractile performance that is not explained
by the extent of coronary artery disease or ischemic
damage. So far there is only very limited experience with
cardiac CT in the assessment of cardiomyopathies, but
using morphologic and functional information from coronary CT angiography data permits accurate differentiation of ischemic from nonischemic cardiomyopathy.
Although high-grade coronary artery stenoses are
known to occur in as many as 14% of high-risk patients
without coronary calcifications, this finding is very uncommon in low- or intermediate-risk patients (particularly

when asymptomatic). Nevertheless, coronary calcium


scoring has successfully been used for differentiating ischemic from nonischemic dilated cardiomyopathy. Although a
sensitivity of 99% has been reported for differentiating
ischemic from dilated cardiomyopathy by assessing the
coronary calcium score, one has to be aware that, particularly in symptomatic patients with a high risk of coronary
artery disease, there might be isolated noncalcified plaque.
Thus, unenhanced and contrast-enhanced cardiac CTcan
comprehensively evaluate for ischemic cardiomyopathy.
Primary assessment of cardiomyopathies is an evolving
indication for cardiac CT.

128

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

n Figure 12-3 A, Prospectively electrocardiographically triggered


unenhanced computed tomography (CT) (120 kV, 30 mA, 24  1.2 mm,
3-mm slice thickness) revealed no coronary calcifications (coronary
calcium score 0) (left). Retrospectively electrocardiographically gated
coronary dual-source CT angiography (120 kV, 410 mArot 2  64  0.6
mm, 70 mL iopromide 300), showed total occlusion of the left anterior
descending artery (middle and right; arrows). All other epicardial vessels
were normal. B, Global left ventricular function was assessed from 6-mm
double-oblique short-axis images using the modified Simpson method.
Ejection fraction at rest was 37%. Short-axis images obtained during
end-systole (left) and end-diastole (right) showed a lack of wall thickening
in the mid anterior segment of the left ventricle (arrows). C, The polar
map shows a reduced wall thickening not only in the anterior wall, but
also in parts of the basal lateral wall, suggesting that the left ventricular
dysfunction was impaired beyond what coronary status suggested.
The patient was diagnosed with ischemic cardiomyopathy.

Chapter 12

Case 4

The Left Ventricle

129

Ischemic Cardiomyopathy (Positive Coronary Calcium Score)

A 75-year-old man presented with intermittent angina. Except for an episode of


chest pain 9 years ago, the patient reported an uneventful medical and cardiac
history. He declined invasive catheter angiography. The calculated 10-year
Framingham risk score was 40%. He was referred for additional diagnostic workup
(Fig. 12-4).

B
n Figure 12-4 A, Prospectively electrocardiographically triggered, noncontrast, dual-source computed tomography (CT) was performed for
the detection and quantification of coronary artery calcifications. There were some calcifications in the left anterior descending artery (LAD) and
the left circumflex artery. The coronary calcium score (Agatston method) was 297 units. B, Curved multiplanar reformats from a retrospectively
electrocardiographically gated coronary dual-source CT angiography showed several calcified and noncalcified plaques in the left anterior
descending artery (left) and the left circumflex artery (middle). Three-dimensional volume-rendered image shows the course of the patent LAD.
The absence of an artery in the right ventricular groove corresponds to a chronic occlusion of the right coronary artery (right).
Continued

CO MMENTS
Cardiac CT in a symptomatic, high-risk patient is considered inappropriate. Nevertheless, the patient declined

an invasive evaluation and was therefore referred for cardiac CT. The combined assessment of ventricular morphology and function holds the potential to diagnose

130

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

D
n Figure 12-4contd C, Evaluation of ventricular morphology revealed a mild left ventricular dilation. The inner end-diastolic diameter of
59 mm was measured on four-chamber view images (left, dotted arrow). Note the absence of the contrast-enhanced right coronary artery in the
right ventricular groove. In addition, the myocardium showed thinning in the inferior and lateral wall on double-oblique short-axis images (right,
arrows). D, Functional assessment of the cardiac CT data using the area length method on systolic (left) and diastolic (right) two-chamber view
images revealed a markedly reduced ejection fraction of 30%. For calculation of ventricular volumes from two-chamber view images, the length
from the apex to the mitral valve plane (red arrows) and the cross-sectional area are needed. Considering morphologic and functional
information, the patient was diagnosed with ischemic cardiomyopathy.

cardiomyopathy. As most cardiomyopathies present with


dilation of the left ventricle, reference values for assessing left ventricular end-diastolic diameter are helpful.
Corresponding to echocardiographic imaging, the enddiastolic short-axis diameter values can be categorized
as follows: 56 mm or less normal, 57 to 62 mm mild
dilation, 63 to 70 mm moderate dilatation, more than
70 mm severe dilation. One caveat in translating
echocardiographic measurements to CT measurements
is the different technique of measurement.

In combination with the assessment of the coronary


arteries, cardiac CT permits the differentiation of ischemic
and nonischemic cardiomyopathies. Studies using 64-slice
CT show a 95% accuracy per patient for detecting coronary artery disease in the setting of cardiomyopathy.
Because coronary artery disease may be associated with,
but not responsible for, cardiomyopathy, one may use
the definition established by Felker and colleagues that
reclassifies patients with single-vessel disease and with
no history of myocardial infarction or revascularization as

Chapter 12

nonischemic unless there is a left main or proximal left


anterior descending artery or multivessel disease. Thus,
for establishing the diagnosis of cardiomyopathy with

Case 5

The Left Ventricle

131

cardiac CT, it is mandatory not only to assess the coronary


arteries, but also to analyze ventricular morphology and
function.

Ischemic Cardiomyopathy (Coronary Shunt)

A 51-year-old man presented with generalized weakness. He had a history of an


intracerebral (basal ganglia) hemorrhage that occurred 7 years ago. Physical
examination revealed pallor and a systolic murmur. On echocardiography, valvular
heart disease was excluded, but there was a left ventricular dilation with an enddiastolic diameter of 63 mm. Multiple atypical mediastinal vessels were identified.
The patient was referred for further diagnostic workup (Fig. 12-5).

B
n Figure 12-5 A, Retrospectively electrocardiographically gated dual-source computed tomography (CT) of the chest and the heart was
performed. For dose reduction, a dedicated scanning algorithm that limits electrocardiographic gating to the region of the heart was applied.
Coronary artery disease was ruled out by coronary CT angiography. CT angiography of the chest, however, revealed an extensive mediastinal
arteriovenous malformation with feeding vessels from both subclavian arteries (left) and the abdominal aorta. There were also shunts from the
periphery of the right coronary artery (middle) and the proximal part of the left circumflex artery (right, arrows). B, The two-chamber view
showed several irregular vessels in the mediastinum (arrows) and confirmed mild dilation of the left ventricle, corresponding to the
echocardiographically determined end-diastolic diameter of 63 mm. The myocardium otherwise appeared normal without signs of reduced
perfusion. Assessment of left ventricular volumes applying the modified Simpson technique showed a reduced ejection fraction of 43% (cardiac
output 6.3 L/min). Evaluation of the global left ventricular function was feasible, although electrocardiographic pulsing with 96% dose reduction
was applied with subsequently heavily increased image noise on systolic images. Considering these findings, the diagnosis of cardiomyopathy
caused by a chronic arteriovenous shunt was established.
Continued

132

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

250

200

HU

150

100

50

0
5

10

15

20

25

30

Seconds

n Figure 12-5contd C, In addition to geometric analysis of the left ventricular volumes, indicator dilution technique was applied in
the pulmonary artery using the iodinated contrast agent as the indicator (left). From fitted time-attenuation curves in the pulmonary artery
right ventricular output (CO) can be calculated using a modification of the Stewart-Hamilton equation, where Q is the amount of indicator
injected and c(t) is indicator concentrations as a function of time. The right ventricular output, as determined from the corresponding (fitted)
time-attenuation curve (right), was 3.6 L. The shunt volume was therefore quantified with approximately 44%. This was in agreement with
angiographic determination of the shunt fraction. HU, Hounsfield units. Circle indicates region of interest for measurement.

COMMENTS
Cardiomyopathy does not necessarily result in an obvious change of myocardial morphology on CT. Instead,
the diagnosis of cardiomyopathy on cardiac CT always
requires evaluation of the coronary arteries to exclude
coronary artery disease in addition to the functional
assessment of the left ventricle. Coronary artery anomalies are readily assessed using cardiac CT, which is considered an appropriate indication for cardiac CT. It is
also suited for the assessment of coronary fistulae, but

Case 6

there are no recommendations on this particular issue.


In addition, CT angiography permits the assessment
of the extracardiac anatomy as seen with this complex
vascular malformation. Cardiac CT provides the ability
to comprehensively evaluate a broad variety of cardiovascular malformations. The assessment of their
functional significance, however, must be considered
experimental and is currently not recommended for
routine clinical use.

Dilated Cardiomyopathy (Negative Coronary Calcium Score)

A 57-year-old man was admitted to the hospital with generalized weakness and
moderate dyspnea. He had no history of cardiac disease. His cardiac risk factors were
obesity (body mass index, 32 kg/m2) and hypertriglyceridemia. His Framingham risk
score was 14%. On admission, a chest x-ray was obtained, demonstrating an
enlargement of the left ventricle (Fig. 12-6).

Chapter 12

The Left Ventricle

133

C
n Figure 12-6 A, Unenhanced electrocardiographically gated 16-slice computed tomography (CT) was performed for further evaluation
of the patients cardiovascular risk. There were neither coronary nor valvular calcifications, indicating a low likelihood of obstructive
coronary artery disease and low cardiovascular risk. B, Axial view from the caudal part of the scan volume shows the massive enlargement of
the left ventricle as it is typically seen in dilated cardiomyopathy. In addition, a subendocardial thrombus is depicted (arrows). The latter
presents as a hypodense, intracavitary mass when compared with the left ventricular myocardium. C, Transthoracic echocardiography was
limited due to the patients obesity, and therefore magnetic resonance imaging was performed. Systolic (left) and diastolic (right) short-axis
magnetic resonance images confirmed the presence of the left ventricular thrombus (arrows) that was detected by unenhanced CT. Note
the extensive left ventricular dilation and the reduced systolic contraction.

CO MMENTS
Assessing coronary calcifications in patients with an intermediate cardiovascular risk is considered an appropriate
indication for unenhanced cardiac CT. In patients with
suspected cardiac pathology, it helps to distinguish
coronary artery disease from other underlying pathology.
Coronary calcium scoring has successfully been used for
differentiating ischemic from nonischemic causes of
dilated cardiomyopathy. A sensitivity of 99% and a specificity of 83% have been reported for differentiating

ischemic from dilated cardiomyopathy using electronbeam CT for detecting coronary calcifications. However,
one has to be aware that, particularly in patients with
either symptoms or a high risk of obstructive coronary
artery disease, coronary calcification may be absent in
the setting of atherosclerotic vascular disease such as
described in case 3. Nevertheless, the detection of coronary calcifications in dilated cardiomyopathy is a very
helpful indicator for differentiating ischemic from nonischemic causes of cardiomyopathy.

134

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 7

Valvular Cardiomyopathy

A 36-year-old man was admitted to hospital with mild dyspnea. He had no history of
cardiac disease. An echocardiogram showed dilated cardiomyopathy with a dilated left
ventricle (end-diastolic diameter of 62 mm) and an ejection fraction of 44%. Based on
these findings, the patient was referred to the hospital for a diagnostic workup including
exclusion of ischemic cardiomyopathy (Fig. 12-7). The only risk factor was an elevated
total cholesterol level. His 10-year Framingham risk score was 2%.

B
n Figure 12-7 A, The patient underwent unenhanced and contrast-enhanced dual-source coronary computed tomography (CT) for exclusion of
coronary artery disease. There were no calcifications present on CT. Coronary artery stenosis was excluded from coronary dual-source CT angiography.
The right coronary artery (left) and left anterior descending artery (right) were normal, but there was an eccentric, nonstenotic plaque in the proximal
left circumflex artery with an outward remodeling (arrows, inset). B, Left ventricular function was assessed from double-oblique short-axis images.
End-diastolic images confirmed dilation of the left ventricle (CT left ventricular inner end-diastolic diameter, [dashed arrow] 61 mm). The ejection fraction,
as calculated from end-diastolic (left) and end-systolic (right) short-axis images, was 43%. These findings were in agreement with echocardiography.
Continued

Chapter 12

The Left Ventricle

135

C
n Figure 12-7contd C, Assessment of the heart valves revealed an incomplete diastolic closure of the aortic valve, indicative of aortic
regurgitation (left). The regurgitant orifice area, as assessed from multiplanar reformats orthogonal to the aortic valve (right), was 0.31 cm2,
indicating moderate aortic insufficiency. Detail view shows planimetry of the regurgitant orifice area. From CT data, the patient was diagnosed
as having valvular cardiomyopathy. The diagnosis was confirmed using transesophageal echocardiography.

CO MMENTS
Most cardiomyopathies present with a variable degree of
left ventricular dilation. Cardiac CT has the potential to
distinguish the different types of cardiomyopathy
(dilated vs. hypertrophic) and particularly helps to recognize different underlying causes of disease. Cardiac
CT provides data complementary to other methods
concerning valvular heart disease. Aortic regurgitation,

Case 8

one potential cause of valvular cardiomyopathy, is suggested by incomplete closure of the aortic valve on cardiac CT and is diagnosed with a sensitivity of 70% and
a positive predictive value of 100%. However, other
causes of nonischemic cardiomyopathy, such as metabolic or general system diseases, have nonspecific findings on cardiac CT. There are no guidelines regarding
the use of CT as a primary modality in cardiomyopathy.

Hypertrophic Obstructive Cardiomyopathy

A 69-year-old woman with a history of hypertrophic obstructive cardiomyopathy


was referred to the hospital for cardiovascular evaluation and, if eligible, for
transcoronary ablation of septal hypertrophy. Because of metallic implants, she could
not undergo preinterventional MRI and was therefore referred for cardiac CT for
evaluation of the left ventricular myocardium (Fig. 12-8).

CO MMENTS
According to the Multi-Ethnic Study of Subclinical
Atherosclerosis (www.mesa-nhlbi.org) data, the coronary calcium score is considered elevated if it exceeds
the 75th percentile. Considering this information,
coronary calcium scoring was helpful for excluding
ischemic heart disease. This is also in accordance with
previously published data on the use of coronary
calcium scoring in the assessment of dilated cardiomyopathy. CT reliably depicts cardiac morphology,
and the potential of electron-beam CT to assess function in hypertrophic obstructive cardiomyopathy
patients has been shown. However, there are no data
on multislice spiral CT (MSCT).

MRI of hypertrophic obstructive cardiomyopathy


including delayed-contrast enhancement is considered
appropriate according to the ACCF/ACR/SCCT/
SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness
criteria. However, in this patient, MRI was not feasible
and contrast-enhanced cardiac CT was performed as an
alternative cross-sectional imaging technique. Cardiac
CT can provide data on ventricular morphology in a
manner very similar to that of MRI. Even delayedcontrast enhancement can be assessed. Due to the limited assessment of stress function and radiation burden,
CT is normally not the method of choice in the assessment of cardiomyopathies, but is a valuable diagnostic
alternative if MRI is not feasible/available. Its potential
to assess extracardiac structures may influence therapy.

136

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

n Figure 12-8 A, Coronary calcium scoring was performed. The


coronary calcium score according to Agatston was 78.6 units. This
result lies between the 50% and 75% age- and sex-adapted percentile
according to the Multi-Ethnic Study of Subclinical Atherosclerosis
(www.mesa-nhlbi.org). B, Six-millimeter multiplanar reformation
from contrast-enhanced cardiac 16-slice computed tomography (CT)
(16  0.75 mm, 120 kV, 550 mAeff, 80 mL iopromide 370) along the
modified three-chamber view (left) shows an asymmetrical thickening
of the myocardial septum with a diastolic thickness of 26 mm (dotted
arrow). This finding is evidentiary for hypertrophic obstructive
cardiomyopathy. Note the subendocardial hypodensity in the septum
(arrows) indicating reduced perfusion in the hypertrophic
myocardium. Five-millimeter axial images from the same cardiac CT
examination reconstructed with a full field of view also revealed a
4.3-cm mass of the right adrenal gland (right, arrows) that was
histologically proven to be a metastasis of transitional cell carcinoma.
C, Venous-phase, contrast-enhanced abdominal CT (16  1.5 mm,
120 kV, 165 mAeff, 100 mL iopromide 370, 70-second delay time,
5-mm slice thickness) for evaluation of the adrenal mass also showed
irregular delayed contrast enhancement of the ventricular septum
(arrows). This finding is well-known from delayed contrast-enhanced
magnetic resonance imaging. Because extracellular contrast agents
used for CT have distribution volumes similar to those of gadolinium
complexes, contrast-enhanced CT can also depict delayed myocardial
contrast enhancement to some extent.

Chapter 12

Case 9

The Left Ventricle

137

Subvalvular Aortic Stenosis

A 19-year-old woman with a history of transposition of the great vessels and multiple
previous cardiac surgeries including pacemaker implantation was referred for further
workup after syncope. Echocardiography and cardiac catheterization showed an
increased mean pressure gradient of 58 mm Hg in the left ventricular outflow tract.
Because cardiac MRI was not recommended due to the cardiac pacemaker,
prospectively ECG-gated cardiac CTwas performed for assessing morphology of the
left ventricular outflow tract before surgery (Fig. 12-9).

n Figure 12-9 A, Prospectively electrocardiographically triggered


arterial-phase computed tomography (CT) image along the threechamber view shows hypertrophy of the subvalvular septum (arrows),
resulting in a stenosis of the left ventricular outflow tract. The
end-diastolic diameter of the septum was 18 mm (dotted arrow).
B, Double-oblique short-axis CT images confirm the hypertrophy of
the basal septum. After repeated surgical reconstruction of the right
ventricular outflow tract with homo- as well as
polytetrafluoroethylene grafts, CT revealed a moderate stenosis of
the right ventricular outflow tract (asterisk) due to muscular
hypertrophy (arrows) and severe calcifications of the
polytetrafluoroethylene graft (arrowheads). The patient underwent
cardiac surgery, which confirmed both diagnoses. Resection of the
subvalvular aortic stenosis and pulmonary valve replacement were
successfully performed.

CO MMENTS
Assessment of complex congenital heart disease including anomalies of the great vessels, cardiac chambers,
and valves is an appropriate indication for cardiac CT.
Cross-sectional images can provide valuable information
for planning surgery including sizing of implants.

In these patients, effective dose reduction is feasible


by omitting unenhanced images because the coronary
arteries do not have to be assessed. For the same reason,
prospective electrocardiographic triggering is recommended. The combination of both measures can substantially reduce the effective radiation exposure to
values less than 3 to 5 millisieverts (mSv).

138

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 10

Myocardial Hypertrophy and Subendocardial Ischemia in Aortic


Stenosis

A 49-year-old man was admitted to the emergency department with acute chest pain
after syncope. He was pale, diaphoretic, and reported dyspnea. The patient had an
uneventful medical history. The only cardiovascular risk factor was a 30-year history
of smoking. His 10-year Framingham risk score was 13%. For further diagnostic
workup, prospectively ECG-gated CT of the chest was performed (Fig. 12-10).

C
n Figure 12-10 A, Nonenhanced computed tomography (CT) did not show any coronary calcifications, but the aortic valve leaflets were
heavily calcified with a calcium hydroxyapatite equivalent of 563 mg. This finding corresponds to severe aortic stenosis. B, Retrospectively
electrocardiographically gated coronary CT angiography excluded the presence of coronary artery stenosis or aortic dissection. The aortic valve
area as determined planimetrically by CT was 0.5 cm2, confirming high-grade aortic stenosis. C, Short-axis (left) and two-chamber (right) views
showed diffuse left ventricular hypertrophy. Myocardial mass as determined using the Simpson method was increased with a left ventricular
mass index of 112 g/m2.
Continued

Chapter 12

The Left Ventricle

139

n Figure 12-10contd D, Short-axis (left) and two-chamber


(right) views computed from ungated CT data that were acquired
only a few seconds after the cardiac CT scan show a marked
subendocardial hypodensity, indicating diffusely reduced
perfusion. Although this finding is normally not visible on routine
arterial-phase CT of the heart, decreased left ventricular perfusion
is known to be associated with aortic stenosis, even in cases of
normal epicardial vessels. E, Axial images of the lung show alveolar
infiltrations that indicate lung edema. Based on the
comprehensive CT examination, the diagnosis of decompensated
high-grade aortic stenosis with left symmetrical ventricular
hypertrophy was made.

CO MMENTS
The indication for CT for characterizing cardiac valves
in patients with technically limited images from other
cross-sectional imaging modalities is considered uncertain. Nevertheless, ECG-synchronized CT is increasingly used in emergency settings. Although its most
common indication is to rule out coronary artery disease
and Stanford A aortic dissection, it holds the potential to
assess complex problems with myocardial involvement.
Aortic stenosis is commonly associated with diffuse
myocardial hypertrophy. Cardiac CT not only allows
for the quantification of the aortic valve area by planimetry, but a direct relationship exists as well between

Case 11

the extent of aortic valve calcification and the likelihood


of significant aortic stenosis. It also permits the assessment of myocardial mass, which is considered an important prognostic factor in aortic stenosis.
Reduced myocardial perfusion may be detected by
arterial phase CT. Although this finding can frequently
be seen in myocardial infarction, it is typically not visually assessable in case of aortic stenosis. Although its
causes are controversial, reduced perfusion in patients
with aortic stenosis and normal epicardial vessels seems
to be associated with diffuse left ventricular hypertrophy. Both issues can be assessed using CT data.

Acute and Chronic Myocardial Infarction

A 66-year-old man was referred for cardiac CT to exclude in-stent thrombosis 6 days
after stent placement for acute myocardial infarction (Fig. 12-11). He had a history
of known chronic occlusion of the right coronary artery. His risk profile included
arterial hypertension, moderate obesity, and hypercholesterolemia.

140

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

B
n Figure 12-11 A, An initial cardiac 16-slice computed tomography (CT) scan was performed for exclusion of in-stent thrombosis. One year later,
the patient became symptomatic again. He was referred for coronary CT angiography to assess stent patency. Face-to-face comparison of short-axis
and four-chamber view images in acute (6 days) and chronic (1 year) myocardial infarction show the changes in myocardial morphology over time. In
acute myocardial infarction, there is a slightly hypodense area in the basolateral myocardium, whereas normal wall thickness is preserved (top,
arrows). One year after myocardial infarction, the left ventricle shows a remodeling with a local thinning of the infarcted myocardium (bottom,
arrows). B, Polar plots of the wall thickening in acute (left) and chronic (right) myocardial infarction prove the severely reduced or even missing wall
thickening (blue) in the basal segments of the left ventricle with some functional recovery in the mid and basal sections of the anterior wall.

Chapter 12

CO MMENTS
In patients with a history of myocardial infarction, assessment of function using coronary CTangiography data provides valuable information on the myocardium. Combined
with wall motion at rest and end-diastolic wall thickness,
evaluating for myocardial areas of hypoattenuation can

Case 12

The Left Ventricle

141

provide insight to the extent of disease. Moreover, cardiac


CT also allows for the evaluation of myocardial remodeling. The application of coronary CTangiography for assessing stent patency in symptomatic patients is an evolving
indication due to limited accuracy under certain conditions
such as smaller stent diameter.

Ischemic Ventricular Aneurysm

A 67-year-old woman was admitted to the hospital for implantation of a biventricular


pacemaker. She had a history of ischemic cardiomyopathy with recurrent myocardial
infarctions and left ventricular aneurysm. Prospectively ECG-triggered CT of the
heart was performed for planning biventricular pacemaker implantation (Fig. 12-12).

n Figure 12-12 A, Arterial-phase computed tomography (CT) images


along the two-chamber view and the short-axis view show a large
aneurysm of the left ventricle (left). Although the left ventricular
myocardium is globally thinned, there is virtually no viable myocardium,
but nonenhancing fibrotic tissue in the region of the aneurysm. Shortaxis images confirm these findings with myocardial tissue in the basal
section of the left ventricle (middle) and only fibrotic tissue in the inferior
segments of the mid and apical part of the left ventricle (right). Increased
attenuation values can be seen in this section, corresponding to akinesia
from myocardial fibrosis. As a consequence of reduced regional wall
motion, the left ventricular apex shows more concentrated contrast
material as a result of insufficient pump function in this region.
B, Delayed imaging approximately 5 minutes after contrast injection
shows delayed contrast hyperenhancement in the fibrous scar tissue and
the septum (arrows). This finding has been associated with a reduced rate
of recovery of regional function and lower ejection fraction. Note the
artifacts from pacemaker lead in the right ventricle.

CO MMENTS
Despite reperfusion therapy, approximately 20% of
patients who have a myocardial infarction will experience left ventricular enlargement, and a ventricular
aneurysm will develop in 5%. Ventricular remodeling
results in deteriorated pump function and subsequent

heart failure. Biventricular pacemaker implantation and


reductive surgery are potential therapeutic approaches
to this issue. CT is well suited to depict the extent of
disease including postischemic changes to the myocardium including fibrotic changes. It helps in planning
interventional and surgical procedures, requiring only a
single comprehensive examination.

142

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 13

Postoperative Ventricular Aneurysm

A 75-year-old man with a history of coronary artery bypass surgery and aortic
stenosis (aortic valve area of 0.6 cm2) was referred to cardiovascular surgery for
routine checkup after apicoaortic conduit 6 months before. Echocardiography
revealed an outpouching in the area of the ventricular anastomosis, and CT was
performed to assess the conduit (Fig. 12-13).

n Figure 12-13 A, Curved


multiplanar reformats from thinsection axial computed
tomography (CT) images show an
extensive outpouching at apex of
the left ventricle, directly beneath
the conduit, from a ventricular
pseudoaneurysm. The course of
the aortic valve bypass and the
extent of the pseudoaneurysm are
clearly depicted. B, Short-axis (left)
and four-chamber view (right)
cardiac CT images provide a more
detailed view of the entrance of the
pseudoaneurysm (arrows). Contrast
differences with less diluted
(hyperdense) contrast in the
aneurysm and diluted contrast in
the ventricles indicate the
functional exclusion of the
aneurysm from the circulation.

COMMENTS
Nonischemic ventricular pseudoaneurysms may be
due to congenital, traumatic, infectious, and iatrogenic
reasons. Depending on the consistency of the aneurysm
wall, they can be classified as true aneurysm, pseudoaneurysm, mixed aneurysm, and pseudo-false aneurysm.
Imaging with a cross-sectional technique, such as cardiac CT, is essential in these cases to define the anatomic

relationships. In addition, the coronary status must be


assessed before corrective surgery. There are only sporadic reports of the use of CT in the assessment of the
different types of left ventricular aneurysms. So far,
ECG-gated CT of the heart is the only imaging modality that provides all required information in a single
examination.

Chapter 12

Case 14

Myocarditis

A 51-year-old woman presented with retrosternal pain after an episode of enteritis.


Physical examination revealed mild fever. The electrocardiogram showed diffuse
changes including left bundle-branch block. C-reactive protein (112 mg/L), creatine
kinase (254 U/L), and troponin l (1.6 g/L) levels were elevated. On
echocardiography, there were no wall motion abnormalities, and global left
ventricular function was preserved. She was evaluated by cardiac CT
(Fig. 12-14).

B
n Figure 12-14 Coronary computed tomography (CT) angiogram is normal. A, Arterial-phase short-axis
(left and middle) and three-chamber view (right) images showed a homogeneous enhancement of the left
ventricular myocardium. There were no signs of perfusion anomalies. B, Delayed image acquisition
approximately 10 minutes after contrast administration revealed several subepicardial foci of delayed
contrast enhancement (arrows). This finding is similar to the typical magnetic resonance imaging
characteristics of myocarditis. Iodinated and gadolinium-based extracellular contrast agents have very
similar pharmacokinetics and virtually identical distribution volumes forming the basis for comparability
of delayed contrast enhancement in magnetic resonance imaging and CT.
Continued

The Left Ventricle

143

144

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

C
n Figure 12-14contd C, From magnetic resonance imaging studies, typical delayed contrast
enhancement patterns are known for differentiation of ischemic (1 and 2) and nonischemic (37) disease
of the myocardium. In a simplified approach, some typical delayed contrast enhancement patterns are
illustrated, depending on their location. Ischemic: 1 nontransmural myocardial infarction with
subendocardial contrast enhancement; 2 transmural myocardial infarction; nonischemic
mid myocardial. Nonischemic: 3 dilated cardiomyopathy, myocarditis; 4 sarcoidosis, myocarditis,
Fabrys disease; 5 hypertrophic cardiomyopathy; subepicardial; 6 myocarditis, sarcoidosis, Fabrys
disease, Chagas disease, global subendocardial; 7 amyloidosis, systemic sclerosis, posttransplantation
reaction.

COMMENTS
Acute myocarditis is an infectious or immunologic disease
with a variable spectrum of clinical patterns. It can be
asymptomatic, but it can also be responsible for acute
cardiac failure. On histology, acute myocarditis shows
interstitial lymphocytic infiltration, cell damage, interstitial edema, and hyperemia. Iodinated contrast agents such
as gadolinium chelates have a nonspecific extracellular
distribution volume. Myocyte membrane rupture with
subsequent increased extracellular space and increased vascular permeability in combination with decreased local
clearance explain delayed-contrast enhancement in a

Case 15

variety of ischemic and nonischemic diseases including


myocarditis. Knowledge about typical enhancement patterns is helpful to distinguish the different entities.
Contrast-enhanced MRI as the reference method in
myocarditis accurately depicts the site and activity of
inflammation. There is only very limited experience
with ECG-gated CT in myocarditis. In a small series
of 11 patients, there was a good correlation between
delayed-enhancement patterns as seen with CT and
MRI (r 0.92). The currently available data indicate
the potential use of CT in myocarditis as an alternative
to MRI.

Ventricular (Septal) Diverticulum

A 64-year-old man experiencing chest pain was referred for coronary CT


angiography. His risk factors included smoking, hyperlipidemia, and a family history
of myocardial infarction. The calculated 10-year Framingham risk score was 16%.
Coronary CT angiography revealed a 50% stenosis of the left anterior descending
artery (Fig. 12-15).

Chapter 12

The Left Ventricle

145

A
n Figure 12-15 Short-axis (A) and three-chamber view (B) images
of the left ventricle reveal an outpouching from the left ventricle
in the mid anterior septum (arrows), representing the typical
computed tomography finding in ventricular diverticula. Ventricular
diverticula may occur in any part of the ventricle.

CO MMENTS
From autopsy series, ventricular diverticula were
thought to occur in approximately 0.4% of patients,
but with the increasing use of cross-sectional imaging
of the heart, the number appears to be higher, with as
many as 2.2% of patients in a recent imaging series.
Diverticula may be considered muscular or fibrous,
depending on the amount of myocardial fibers involved.

Case 16

Muscular diverticula tend to show synchronous contractile function, whereas fibrous forms commonly
present with akinetic or dyskinetic contractile function.
Considerations within the differential diagnosis
include ventricular septal defects, small ventricular
aneurysms (ischemic or traumatic), and left ventricular
noncompaction.

Left Ventricular Noncompaction (Courtesy of Carlson/Taylor)

The patient was a 35-year-old man with palpitations and presyncope. His
electrocardiogram and echocardiogram at admission were normal. Ambulatory
electrocardiographic monitoring showed nonsustained polymorphic ventricular
tachycardia (Fig. 12-16).

146

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

evaluation of patients with known or suspected cardiomyopathy. There are only scarce data on the CT imaging of isolated left ventricular noncompaction. The
published data show the value of CT for the assessment
of this complex disorder because it holds the potential to
exclude coronary artery disease and to provide all relevant diagnostic criteria for this disorder: structure and
distribution of the abnormal myocardium, evidence of
deeply perfused intertrabecular recesses, trabecular
[inner]-to-compact [outer] diastolic ratio (>2.3), and
absence of coexisting cardiac abnormalities.

SUGGESTED READINGS
Normal Left Ventricular Function
Cerqueira MD, Weissman NJ, Dilsizian V, et al: American Heart Association Writing Group on Myocardial Segmentation and Registration for Cardiac Imaging. Standardized myocardial segmentation
and nomenclature for tomographic imaging of the heart: A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American
Heart Association, Circulation 105:539542, 2002.
Mahnken AH, Bruder H, Suess C, et al: Dual-source computed
tomography for assessing cardiac function: A phantom study, Invest
Radiol 42:491498, 2007.
Salton CJ, Chuang ML, ODonnell CJ, et al: Gender differences and normal left ventricular anatomy in an adult population free of hypertension.
A cardiovascular magnetic resonance study of the Framingham Heart
Study Offspring cohort, J Am Coll Cardiol 39:10551060, 2002.

Ischemic Heart Failure

B
n Figure 12-16 A, Contrast-enhanced 64-slice computed
tomography (CT) excluded obstructive coronary artery disease.
Multiplanar reformats from the cardiac CT data showed a twolayered appearance of the left ventricular myocardium. At the
thinnest portion of the apex (arrow), the diastolic ratio between the
inner trabecular layer and compacted epicardial layer exceeded 4.0.
B, Multiplanar reformations along the three-chamber (top left),
short-axis (top right), four-chamber (bottom left), and two-chamber
(bottom right) views of the heart showed the distribution of the
noncompacted myocardium. The anterior, lateral, inferior, and
apical parts of the left ventricular myocardium are uniformly
involved with an average noncompacted-to-compacted ratio of 2.4.

COMMENTS
Isolated left ventricular noncompaction is a rare disorder caused by an intrauterine arrest of myocardial fiber
and meshwork compaction. Clinical findings include
heart failure, ventricular arrhythmias, and thromboembolic events. Except for the evaluation for arrhythmogenic right ventricular cardiomyopathy, which is
considered an appropriate indication for cardiac CT,
there are no recommendations for the use of CT in the

Brodoefel H, Reimann A, Klumpp B, et al: Sixty-four-slice CT in the


assessment of global and regional left ventricular function: Comparison with MRI in a porcine model of acute and subacute myocardial
infarction, Eur Radiol 17:29482956, 2007.
Butler J, Shapiro MD, Jassal DS, et al: Comparison of multidetector
computed tomography and two-dimensional transthoracic echocardiography for left ventricular assessment in patients with heart failure, Am J Cardiol 99:247249, 2007.
Ghostine S, Caussin C, Habis M, et al: Non-invasive diagnosis of
ischaemic heart failure using 64-slice computed tomography, Eur
Heart J Apr 1 [Epub ahead of print].
Mahnken AH, Koos R, Katoh M, et al: Sixteen-slice spiral CT versus
MR imaging for the assessment of left ventricular function in acute
myocardial infarction, Eur Radiol 15:714720, 2005.
Stolzmann P, Scheffel H, Trindade PT, et al: Left ventricular and left
atrial dimensions and volumes: Comparison between dual-source
CT and echocardiography, Invest Radiol 43:284289, 2008.

Ischemic Cardiomyopathy
Budoff MJ, Shavelle DM, Lamont DH, et al: Usefulness of electron
beam computed tomography scanning for distinguishing ischemic
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Chapter 12
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Dilated Cardiomyopathy
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Valvular Cardiomyopathy
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Hypertrophic Obstructive Cardiomyopathy


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The Left Ventricle

147

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Acute and Chronic Myocardial Infarction


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Ischemic Ventricular Aneurysm


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Subvalvular Aortic Stenosis

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Myocardial Hypertrophy and Subendocardial


Ischemia in Aortic Stenosis

Left Ventricular Noncompaction

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Chapter

13

CT Detection of Myocardial
Perfusion, Infarction, and Viability
Richard T. George, Joao A.C. Lima, and Albert C. Lardo

KEY POINTS
l

Multidetector computed tomography (MDCT) myocardial imaging can provide an assessment of myocardial perfusion and viability.

Nonviable myocardium can be detected by MDCT imaging that is performed 5 to 10 minutes after the injection of iodinated contrast.

Delayed-enhancement MDCT imaging of myocardial infarct size correlates well with


delayed enhanced magnetic resonance imaging.

MDCT imaging, performed during the arterial phase of contrast, can detect areas of
reduced myocardial perfusion in the setting of acute and chronic myocardial infarction,
although it tends to underestimate infarct size.

There are several pitfalls with regard to MDCT myocardial viability and perfusion imaging
including beam hardening artifacts, motion artifacts, and fatty infiltration of the myocardium.

Case 1

Delayed-Enhancement Multidetector CT Viability Imaging

A 50-year-old man with a history of Kawasaki disease developed total occlusion of a


very large left anterior descending artery aneurysm. The patient underwent a
delayed-enhancement MDCT study (Fig. 13-1).

148

Chapter 13

CT Detection of Myocardial Perfusion, Infarction, and Viability

149

n Figure 13-1 A, Delayed-enhancement multidetector computed tomography (MDCT) in a patient with an acute anterior myocardial
infarction with an occluded left anterior descending artery. Imaging was performed 10 minutes after the injection of iodinated contrast. Note
the hyperenhanced area of myocardium (arrows) in the septum and anteroapical walls. These are areas of myocardial necrosis and signify
areas of nonviable myocardium. B, Delayed-enhancement MDCT in the same patient. Image is reconstructed in the cardiac short axis. Note
the hyperenhancement involving the anteroseptal myocardial wall. Findings are consistent with an acute anterior myocardial
infarction. (Courtesy of Robert S. Schwartz, MD, and John R. Lesser, MD, Minneapolis Heart Institute.)

CO MMENTS
Iodinated contrast agents share similar late-enhancement contrast kinetics with gadolinium used for
delayed-enhancement MRI of viability. Iodinated contrast agents freely distribute in the intravascular, extravascular, and extracellular spaces over time, but are
excluded from the intracellular space of viable myocytes.
Therefore, nonviable necrotic myocardium, in the

setting of an acute transmural myocardial infarction, will


hyperenhance 5 to 10 minutes after the injection of iodinated contrast. Thus, hyperenhancement noted on
delayed MDCT signifies areas of nonviable necrotic
myocardium in the setting of an acute myocardial infarction (Fig. 13-2). Infarct size, as determined by delayedenhancement MDCT has been shown to compare well
with delayed-enhancement magnetic resonance imaging,
however with more limited contrast-to-noise ratios.
A

n Figure 13-2 Delayed-enhancement multidetector computed tomography (MDCT) viability in a canine model of acute anterior myocardial
infarction. Note the hyperenhancement in the anterior myocardial wall in the MDCT image (left). Histopathology samples (right) were taken from the
infarct, (A) and normal myocardium (B). The infarcted myocardium demonstrates evidence of acute myocyte necrosis, including extensive contraction
band necrosis and neutrophil infiltration compared with normal-appearing myocytes in the normal myocardium.

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ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 2

Arterial-Phase, First-Pass Imaging of Chronic Infarction

A 43-year-old man with a history of an ST elevation myocardial infarction involving


the left anterior descending artery 4 years previously presented with recurrent chest
pain. MDCT coronary angiography was performed with first-pass contrast
enhancement (arterial phase) (Fig. 13-3).

n Figure 13-3 Multidetector computed tomography (MDCT) during first pass of the contrast bolus. MDCT shows multiple findings of a chronic
myocardial infarction. A, In the axial view, myocardial thinning of the septum is noted (black arrows). The area of high-attenuation density in the
distal anterior wall represents calcification of an old myocardial infarction (white arrows). B, The oblique two-chamber view shows an area of
hypoattenuation in the mid to distal anterior wall (arrows). CE, Images reconstructed in the cardiac short axis confirm the hypoattenuation and
myocardial thinning of the anterior and septal walls. E, The hypoattenuated area in the left ventricular apex is a thrombus (arrow).

Chapter 13

CT Detection of Myocardial Perfusion, Infarction, and Viability

151

CO MMENTS
Chronic myocardial infarcts, when imaged by MDCT during the first pass of the contrast bolus, often appear hypoattenuated. In this case, the previous myocardial infarction
was a transmural infarct that caused irreversible damage

Case 3

of the anterior myocardial wall and apex and resulted in a


thin myocardial scar that eventually calcified in its apical
portion. Large myocardial infarcts, especially in the anterior wall and apex, are substrate for thrombus formation.

MDCT Myocardial Perfusion Imaging in Obstructive Coronary


Artery Disease

A 59-year-old man with a history of dyslipidemia, hypertension, and tobacco abuse


presented with exertional chest pain radiating to the left arm and jaw. MDCT was
performed on a 320-detector dynamic-volume CT scanner (Fig. 13-4).

n Figure 13-4 A and B, Multidetector computed tomography angiography shows a high-grade stenosis
(white arrows) in the proximal left anterior descending artery that consists of both noncalcified and calcified
plaque (window width 1000, window level 200). C and D, Evaluation of the myocardium reveals a
subendocardial perfusion deficit (black arrows) in the mid to distal anterior wall and apex representing
decreased myocardial perfusion to this territory (window width 400, window level 200).

152

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

COMMENTS
High-grade stenoses, especially if they are located in the
proximal portions of vessels, can result in subendocardial perfusion deficits in the myocardial territory distal
to that vessel. Perfusion deficits secondary to epicardial
coronary artery disease will have a transmural distribution that exhibits a lower attenuation density in the subendocardial layer compared with the subepicardial layer.

Case 4

Caution must be used when examining the myocardium


for perfusion deficits because beam-hardening artifacts
can be mistaken for perfusion deficits. Beam-hardening
artifacts are most common in the distal anterior wall
secondary to x-ray hardening by the contrast in the left
atrium and left ventricle and in the basal inferior wall
where the descending aorta comes in close proximity
to the heart.

MDCT Myocardial Perfusion Imaging after Reperfused


Myocardial Infarction

A 51-year-old man has a history of acute ST elevation myocardial infarction 3 years


previously. Reperfusion therapy was performed; however, the patient had an
extensive myocardial infarction. Three years later, MDCT angiography was
performed to assess for further obstructive coronary artery disease (Fig. 13-5).

n Figure 13-5 A, Multidetector


computed tomography
angiography shows a patent stent
in the left anterior descending
artery. The remainder of the left
anterior descending artery is
without obstructive coronary
disease. B, In the oblique view,
a perfusion deficit is noted in the
anteroapical walls (white arrows).
There is also thinning of the
anterior and apical walls
corresponding to the previous
myocardial infarction in the left
anterior descending artery
territory. (Courtesy of John Hoe,
MD, Mount Elizabeths Hospital,
Singapore.)

COMMENTS
Reperfusion therapy with primary angioplasty and stenting has been shown to reduce morbidity and mortality in
the setting of acute ST elevation myocardial infarction.

However, if performed too late, the result can be a significant loss of myocardium and left ventricular systolic
function. Thinning of the myocardium is consistent
with loss of viable myocardium, as seen with other
modalities such as echocardiography.

Chapter 13

CT Detection of Myocardial Perfusion, Infarction, and Viability

153

PITFALLS OF CT PERFUSION
I M A G ING
Fatty Infiltration of a Chronic Myocardial
Infarction
Figure 13-6 shows fatty infiltration of a chronic myocardial infarction. Hounsfield units (HU) are units of measurement that correlate well with the density of an
object. Unlike magnetic resonance or ultrasound imaging, CT-derived attenuation values are quantitative and
can be used to define the density of a structure or the
iodine content after the administration of iodinated contrast. Without the use of iodinated contrast, the myocardium has attenuation values ranging from 40 to 60 HU.
This can vary depending on the reconstruction algorithm. Contrast-enhanced myocardium with normal
myocardial perfusion typically has an attenuation density ranging from 90 to 130 HU, depending on the
amount of contrast infused.

Beam-Hardening Artifacts
Beam hardening occurs as a result of an increase in photon energy as photons pass through an object. This can
result in cupping artifacts with dark bands or streaks.
Filtering and beam-hardening correction algorithms
can minimize the effect of beam hardening. This is of
crucial importance in CT perfusion imaging because
the measured attenuation density does not reflect the
density of the tissue (Fig. 13-7). Areas affected by beam
hardening can be misinterpreted as perfusion defects.

Motion Artifacts
Due to the limited temporal resolution of todays
MDCT scanners, motion artifacts can occur due to high

n Figure 13-7 Axial image from a multidetector computed


tomography coronary angiogram with significant beam hardening
artifact. Note the area of transmural attenuation density (arrows) in the
basal inferior wall emanating from the descending aorta (*) and
vertebral spine.

heart rates or cardiac arrhythmias. Motion artifacts can


falsely increase or decrease the attenuation density in
myocardium (Fig. 13-8). Thus, they can be mistaken
for perfusion deficits on first-pass imaging or areas of
hyperenhancement on delayed myocardial imaging.
Scanners with improved temporal resolution such as
dual-source CT or with full cardiac coverage such as
320-row detector dynamic-volume CT can minimize
the effects of fast heart rates and cardiac arrhythmias.

n Figure 13-6 Multidetector computed tomography during the first pass of the contrast bolus. Note the
hypoattenuated area in the septum and anterior wall. This is in an area of a previous myocardial
infarction, and myocardial thinning can be appreciated. However, this area of hypoattenuation cannot be
interpreted as an area of hypoperfusion. Measurement of the attenuation density in this area is less than
0 Hounsfield units. Therefore, this is an area of fatty degeneration of an old myocardial infarction.

154

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

n Figure 13-8 Multidetector computed tomography coronary


angiogram shown in the axial plane. The image was acquired during a
premature ventricular contraction resulting in significant motion
artifacts. Areas of low (black arrows) and high (white arrows) attenuation
are noted.

SUGGESTED READINGS
Baks T, Cademartiri F, Moelker AD, et al: Multislice computed tomography and magnetic resonance imaging for the assessment of reperfused acute myocardial infarction, J Am Coll Cardiol 48:144152,
2006.

Francone M, Carbone I, Danti M, et al: ECG-gated multi-detector row


spiral CT in the assessment of myocardial infarction: Correlation with
non-invasive angiographic findings, Eur Radiol 16:1524, 2006.
George RT, Jerosch-Herold M, Silva C, et al: Quantification of myocardial perfusion using dynamic 64-detector computed tomography,
Invest Radiol 42:815822, 2007.
George RT, Lardo AC, Lima JA: Computed tomography for the
assessment of myocardial perfusion. In Gerber TC, Kantor B,
Williamson EE, editors: Computed Tomography of the Cardiovascular
System, London, 2007, Informa Healthcare.
George RT, Silva C, Cordeiro MA, et al: Multidetector computed
tomography myocardial perfusion imaging during adenosine stress,
J Am Coll Cardiol 48:153160, 2006.
Gerber BL, Belge B, Legros GJ, et al: Characterization of acute and
chronic myocardial infarcts by multidetector computed tomography:
Comparison with contrast-enhanced magnetic resonance, Circulation
113:823833, 2006.
Lardo AC, Cordeiro MA, Silva C, et al: Contrast-enhanced multidetector computed tomography viability imaging after myocardial
infarction: Characterization of myocyte death, microvascular
obstruction, and chronic scar, Circulation 113:394404, 2006.
Mahnken AH, Buecker A: Imaging of myocardial viability and infarction. In Gerber TC, Kantor B, Williamson EE, editors: Computed
Tomography of the Cardiovascular System, London, 2007, Informa
Healthcare.
Mahnken AH, Koos R, Katoh M, et al: Assessment of myocardial viability in reperfused acute myocardial infarction using 16-slice computed tomography in comparison to magnetic resonance imaging,
J Am Coll Cardiol 45:20422047, 2005.
Nieman K, Shapiro MD, Ferencik M, et al: Reperfused myocardial
infarction: Contrast-enhanced 64-Section CT in comparison to
MR imaging, Radiology 247:4956, 2008.
Paul JF, Wartski M, Caussin C, et al: Late defect on delayed contrastenhanced multi-detector row CT scans in the prediction of SPECT
infarct size after reperfused acute myocardial infarction: Initial experience, Radiology 236:485489, 2005.
Sanz J, Weeks D, Nikolaou K, et al: Detection of healed myocardial
infarction with multidetector-row computed tomography and comparison with cardiac magnetic resonance delayed hyperenhancement, Am J Cardiol 98:149155, 2006.

Chapter

14

The Right Ventricle


David Bush

KEY POINTS
l

The right ventricle has a complex asymmetrical shape, which is crescent shaped when
viewed in the short axis and has a hook shape when viewed from its superoinferior axis.

The right ventricle has many trabeculations in its apical region. The moderator band is a
structure from the interventricular septum to the apex of the right ventricle that is variable
in size and contains the right bundle of His.

The right ventricle is a thin-walled structure and normally generates a low systolic pressure.
The interventricular septum normally has a concave shape extending into the right ventricle. This concavity may be lost when significant pulmonary hypertension is present.

The right coronary artery perfuses the right ventricular (RV) myocardium, including RV
branches to the free wall. In approximately 80% of individuals, the right coronary artery
also supplies the posterior descending branch to the interventricular septum.

Significant contrast opacification of the inferior vena cava from an upper arm contrast
injection suggests the presence of either tricuspid regurgitation or pulmonary
hypertension.

A wall motion pattern of diffuse hypokinesis of the right ventricle with apical sparing has
been associated with pulmonary embolism.

Arrhythmogenic RV dysplasia (ARVD) is frequently associated with evidence of replacement of normal myocardial density with low-density infiltrates characteristic of fat on computed tomography (CT). However, the presence of fat density is not sufficient to establish
a diagnosis of ARVD.

155

156

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 1

Normal Right Ventricle

A 49-year-old man presented with a 25-minute episode of precordial chest pain. He


had a family history of premature coronary disease, mild hypertension, and
hyperlipidemia. He was evaluated by coronary CT (Fig. 14-1).

Right Coronary
Artery

Right Coronary
Artery

n Figure 14-1 A, Volume-rendered three-dimensional image of the heart from the anterior view showing the right atrium (RA) and right
ventricle (RV). The blood supply to the anterior surface of the right ventricle arises from branches of the right coronary artery. When the right
coronary artery is dominant, it also supplies branches to the inferior region of the interventricular septum and posterior left ventricle. B, Similar
view to image A showing a different subject with a nondominant right coronary artery. In this instance, the right coronary artery supplies only
branches to the left ventricle and not the left ventricle. C, Volume-rendered three-dimensional semitransparent view of the heart with the
contour of the right ventricle highlighted. The right ventricle has a triangular shape seen in this projection.
Continued

Chapter 14

The Right Ventricle

157

Ao

PA

SVC
Outlet

RA

Inlet
Central Apical

n Figure 14-1contd D, Isolated three-dimensional cavity contour of the right ventricle shown in a volume-rendered image. The septal
surface of the right ventricle has a concave surface. E and F, Short-axis images near the base and at the mid ventricular level of the right and left
ventricles that demonstrate the crescent shape of the right ventricle. In a normal right ventricle, the septum has a concave shape into the
right ventricle. G, The right ventricle can be divided into three anatomic regions: an inflow region, which includes the tricuspid valve; a central
apical region; and the outflow region. When viewed along its superoinferior axis, the right ventricle can be visualized as having a J shape. Ao,
aorta; PA, pulmonary artery; SVC, superior vena cava.
Continued

158

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

n Figure 14-1contd HK, Volume-rendered four-chamber


images showing a highlighted contour of the right ventricle
(diastole [H], diastole [I]). Short-axis views showing right ventricular
contours in diastole (J) and systole (K). Right ventricular ejection
fraction can be calculated from multidetector computed
tomography (CT) by subtracting the systolic volume contour from
the diastolic volume contour. Values for right ventricular function
from multidetector CT are similar to those obtained by other
volumetric imaging modalities including radionuclide
ventriculography and cardiovascular magnetic resonance.

COMMENTS
This patient with chest pain and risk factors for coronary artery disease was found to have no coronary calcification, no evidence of noncalcified coronary artery
disease, and normal cardiac structure and function.
The use of coronary CT to evaluate coronary disease
risk and anatomy is the most common use of this technology. Coronary CT angiography can provide valuable
information about cardiac structure and function, however, this is not the primary role of coronary CT angiography because structural and functional cardiac
assessment can usually be obtained by echocardiography
or coronary magnetic resonance imaging without the
use of ionizing radiation or iodine-containing contrast.

It is appropriate to consider coronary CT angiography


when a structural assessment is needed and echocardiography failed to yield adequate images, especially in situations in which the patient is not a candidate for coronary
magnetic resonance imaging. Typically, the entire cardiac structure is imaged as a byproduct of coronary
CT imaging protocols. Functional evaluation of the left
and right ventricles is also possible during coronary
imaging protocols if the acquisition technique involved
the full cardiac cycle (retrospective gating). When there
is a specific interest in imaging the right ventricle, the
timing of the acquisition and contrast injection technique may require adjustment to ensure that the right
ventricle is adequately visualized.

Chapter 14

Case 2

The Right Ventricle

159

Right Ventricular Dilation

A 57-year-old man with a history of alcoholism presented with congestive heart


failure of unknown cause. He had evidence of right-sided volume overload and
significant elevations in liver-associated enzymes. Coronary CT angiography was
performed to evaluate the cause of his heart failure (Fig. 14-2).

LAD
RV

RA

RV

LV
LV
LA

n Figure 14-2 A, Short-axis view of multidetector computed tomography images (3.5 mm thick, maximum intensity projection) showing
biventricular enlargement, with prominently dilated right ventricle (RV). The interventricular septum is slightly D shaped, consistent with
pulmonary hypertension. Note the presence of calcified plaque in left anterior descending coronary artery (LAD). LV, left ventricle. B, Fourchamber view showing dilation of atria and ventricles. LA, left atrium; RA, right atrium. C, A minimum intensity projection, a display technique
in which the minimum intensity voxel is displayed (opposite of maximum intensity projection), thereby emphasizing soft-tissue structure in the
blood pool. Note the prominent moderator band (arrow) in the right ventricle in which the right bundle branch is located and myocardial
trabeculations along the right ventricular wall. D, Oblique 6.35-mm maximum intensity projection of the proximal left coronary artery showing
extensive coronary disease including calcification and high-grade stenoses of the left anterior descending and the left circumflex arteries.
Continued

160

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

n Figure 14-2contd E, Oblique 4-mm thick maximum intensity projection of the right coronary artery. Note the scattered calcification
without contrast present in the right coronary artery with contrast present in the distal right coronary artery. This finding suggests collateral
filling of the distal right coronary artery from the left coronary artery. F, Dilated right atrium and right ventricle and associated reflux of
contrast media into the inferior vena cava (arrow).

COMMENTS
Coronary CT angiography is considered an appropriate
indication for the etiologic evaluation of cardiomyopathy
and congestive heart failure. Typically, this examination
is performed in individuals in whom an atherosclerotic
process is deemed unlikely but still needs to be excluded.
As a volumetric technique, cardiovascular CT provides
accurate delineation of RV morphology, including size
and function. In this individual, coronary CT confirmed
that extensive coronary disease was present as the cause

Case 3

of his cardiomyopathy and not alcoholism as had been


presumed. The study also suggests that the elevation in
liver associated enzymes may be due to hepatic congestion
from right-sided heart failure. Elevated right-sided filling
pressures and tricuspid regurgitation may lead to reflux of
contrast into the inferior vena cava and hepatic veins during the initial venous phase of the contrast injection.
Note, however, that high-contrast flow rates (>3 mL/s)
may also cause contrast reflux into the inferior vena cava
in healthy individuals.

Isolated Right Ventricular Dysfunction

A 55-year-old man with a history of coronary artery disease, including abnormal


results on a stress nuclear perfusion study 2 years earlier, noted the gradual onset of
exertional dyspnea. These symptoms were most noticeable when he was working
outdoors and exposed to cold air. He had no history of asthma or other lung disease.
He was evaluated by coronary CT (Fig. 14-3).

COMMENTS
The patient was hemodynamically stable and mildly
hypertensive and therefore treated with heparin. He
recovered and was diagnosed with protein S deficiency.
Acute RV dysfunction with severely depressed function of the base and mid RV free wall but with preserved RV apical function was described in 1996 by
McConnell and colleagues. After a 41-patient training
cohort was evaluated, they evaluated a retrospective
series of 85 patients with RV dysfunction, 13 of whom

had acute pulmonary embolism. This specific wall


motion abnormality had a 77% sensitivity, 94% specificity, 71% positive predictive value, and 95% negative
predictive value for acute pulmonary hypertension.
They concluded that, among patients with acute pulmonary embolism and RV dysfunction, there is a distinct, regional pattern of RV wall motion. However,
in another series of 161 patients, 107 with massive or
submassive pulmonary embolism, Casazza and colleagues found that McConnells sign of RV wall motion

Chapter 14

The Right Ventricle

161

n Figure 14-3 A, Diastolic-phase, four-chamber 2-mm thick


maximum intensity projection showing a slightly dilated right
ventricle. B, Systolic phase in the same projection showing good left
ventricular contraction. However, right ventricular contraction was
limited to the apex of the right ventricle (arrows). C, Axial 6.3-mm
thick minimum intensity projection of the pulmonary artery at the
level of the bifurcation into left and right pulmonary arteries.
A massive pulmonary embolism is present, with thrombus identified
in both the left and right pulmonary arteries.

abnormality had a much lower power to detect or


exclude the presence of pulmonary embolism from
other causes of RV dysfunction (70% sensitivity, 33%
specificity, 67% positive predictive value, 36% negative
predictive value). Even if not specific for pulmonary

Case 4

embolism, the presence of a RV wall motion abnormality of this type should raise the question of whether further evaluation for pulmonary embolism is appropriate
if the pulmonary arteries were not fully visualized on a
coronary CT scan.

Suspected RV Dysplasia

A 52-year-old man with a history of syncope was referred for a second opinion
regarding RV dysplasia. He presented with a tentative diagnosis of ARVD for which
he had undergone implantation of an internal cardioverter-defibrillator. Family
history included only one other living first-degree relative who did not have evidence
of RV dysplasia. He was evaluated by coronary CT (Fig. 14-4).

162

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

n Figure 14-4 A, Short-axis, 4.8-mm thick minimum intensity projection (window 1095 HU/level
259 HU) of the right and left ventricles showing a dilated right ventricle (note defibrillator lead present).
Note the irregular contour of the left ventricle with low-density areas in the inferior wall and anterior
septum (arrows). B, Short-axis, 2-mm minimum intensity projection (window 400 HU/level 0 HU).
Note the low-density region identified with an attenuation value of 80 Hounsfield units in the right
ventricle. Low-density areas are also noted in the left ventricle. The dark region near the defibrillator lead of
very low Hounsfield units in the right ventricular cavity is artifact due to the defibrillator lead. C, Diastolic
image showing a dilated right ventricle with fatty replacement of myocardium in the anterior septum and
interior wall of the left ventricle (arrows). D, Systolic image showing reduced right ventricular systolic
function with localized right ventricular dysfunction in the superior and anterior portions of the right
ventricle (arrows).

COMMENTS
This patient had evidence of replacement of right and
left ventricular myocardium with low Hounsfield unit
density tissue consistent with a fibrofatty infiltrate. This

finding supports the diagnosis of ARVD/cardiomyopathy. However, it is important to appreciate that imaging
low-density material replacing myocardium is not sufficient to establish the diagnosis of RV dysplasia. Other

Chapter 14

imaging findings that support the diagnosis of RV dysplasia include dilation and reduced function of the right
ventricle with little or no impairment of left ventricular
function, localized aneurysms of the right ventricle,
prominent trabeculations within the RV, and a scalloped
appearance of the right ventricle. However, none of
these imaging findings alone, or in combination with
each other, are sufficient to establish the diagnosis of
RV dysplasia.
A set of diagnostic criteria has been established by the
ARVD Task Force. These criteria require that to establish the diagnosis of ARVD, individuals must have other
abnormalities present in addition to those that would be
seen by imaging modalities such as CT or magnetic resonance imaging. The Task Force criteria for the diagnosis of ARVD require that at least two categories of
abnormalities be present. Imaging modalities can

The Right Ventricle

163

establish the presence of an abnormality of RV structure, which can satisfy one of the categories of abnormality, but at least one other category of abnormality
must also be present. These other categories include evidence of arrhythmias of RV origin, characteristic electrocardiographic changes, or a familial pattern of
inheritance. The diagnosis of RV dysplasia depends on
having a finding in at least two of these categories that
would qualify as major or a combination of at least four
minor criteria.
RV dysplasia has a peak incidence in relatively young
individuals, typically between 20 and 40 years of age,
and can be associated with life-threatening arrhythmias.
The preferred management includes implantation of an
automatic implantable cardioverter-defibrillator to prevent sudden death and having the patient abstain from
vigorous exercise.

Case 5
A 25-year-old man presented with a history of complete dextro-transposition of the
great vessels. A Mustard atrial switch procedure was performed as an infant. He had
recently noticed symptoms of exertional dyspnea. Coronary CT angiography was
performed to evaluate the condition of the atrial baffle placed during the Mustard
procedure (Fig. 14-5).

CO MMENTS
The study showed the baffle to be widely patent. His RV
function was mildly depressed, which was the likely
cause of his symptoms. His symptoms improved with
medical management. Transposition of the great arteries
describes a group of conditions in which the great
arteries are malpositioned relative to the ventricles. It
accounts for approximately 5% to 8% of congenital cardiac malformations. In complete transposition of the
great arteries, the aorta arises from the right ventricle
and the pulmonary artery arises from the left ventricle.
Complete transposition is typically associated with the
aorta arising to the right and anterior to the pulmonary
artery, which has also been termed dextro- or d-transposition. Another nomenclature convention is to describe
transpositions with regard to their atrioventricular and
ventriculoarterial connections as concordant or discordant. The transposition shown in this case has concordant atrioventricular connections but discordant
ventriculoarterial connections. A naming convention
that uses a segmental approach (atria, ventricles, and
arteries) is also used to describe transpositions. Using
this terminology, this case would be described as [S,D,
D], meaning situs solitis of the atria (S), dextro loop ventricles (D), and a dextro location of the aorta.

The Mustard procedure was the first successful operation to correct transposition of the great arteries. The
procedure is performed by removing the atrial septum
and creating a conduit (baffle), which is shaped similar
to a pair of pants. The baffle directs venous blood from
the superior vena cava (one pant leg of the baffle) and
the inferior vena cava (the other pant leg) into the mitral
valve (the pant waist). Blood returning from the pulmonary veins flows around the exterior of the baffle into the
tricuspid valve and then out the systemic right ventricle
into the aorta.
The mortality rate for transposition of the great
arteries before the Mustard procedure was 80% to
90% by the first year of life. After the Mustard procedure, survival rates of approximately 80% at 20 years
of age was common. However, due to problems that
arise, this operation is no longer performed. Arrhythmias, particularly atrioventricular blocks, are common
after this procedure. Presumably this occurs because of
the extensive resection of the intra-atrial septum so that
most patients require pacing at some point after the procedure. Problems with the baffle including partial or
total occlusion can also occur. Coronary CT angiography is well suited to imaging the three-dimensional
shape of the baffle. Right heart failure after a Mustard
correction can be a difficult management problem.

164

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Ao

RV

PA

LV

RV
Baffle

LV
RV

n Figure 14-5 A, Volume-rendered three-dimensional image of the heart showing the aorta arising from
the anterior right ventricle. The right coronary artery is seen arising from the right coronary cusp.
B, Maximum intensity projection in sagittal plane showing complete transposition of the great arteries
with the aorta arising from the anteriorly located right ventricle. The posterior left ventricle gives rise to
the pulmonary artery. C, Short-axis view at the mid ventricular level in corrected transposition of the great
arteries. The Mustard procedure is an atrial switch procedure in which the right ventricle remains
connected to the aorta. Thus, the right ventricle generates systemic pressure levels that lead to hypertrophy.
Note that the right ventricle remains heavily trabeculated compared with the left ventricle. D, Axial view
showing contrast from the superior vena cava being directed to the posterior left ventricle. Note the
thickened walls of the right ventricle.
Continued

LV

Chapter 14

SVC

Baffle

RV

LV

E
n Figure 14-5contd E, Oblique projection showing the
superior vena cava (SVC) and baffle, which direct venous flow into
the posterior left ventricle (LV). No narrowing of the baffle is
present. RV, right ventricle.

The course of right heart failure after a Mustard correction is variable, but when severe and refractory to medical therapy may require conversion to an arterial switch
procedure or heart (or heart-lung) transplantation.

ACKNOWLEDGMENTS
The author acknowledges image contributions of Jeffrey
Goldman, MD, and Edward Shapiro, MD, for this
chapter.

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Chapter

15

Coronary Veins, Systemic Veins,


and Atria
Jerold S. Shinbane, Naser Ahmadi, Jabi Shriki, and Matthew J. Budoff

KEY POINTS
l

The vascular connections to the atria provide conduits for passage of catheters and leads
important to pacemaker and implantable cardiac defibrillator placement (systemic venous
connections), resynchronization therapy and percutaneous mitral valve annuloplasty (coronary venous connections), and ablation procedures including atrial fibrillation ablation
(pulmonary veins). Comprehensive analysis of these structures as well as the atria should
be a routine component to analysis of coronary computed tomography (CT).

The left atrium is more cranial than the right atrium, and one needs to pay special
attention to the location of the left atrial appendage when defining the field of view for
acquisition of images. Special considerations with regard to the field of view must be taken
when anomalies of venous return are considered.

For atrial fibrillation ablation, ungated images can be used to decrease radiation dose.
If the study is also being performed to assess coronary vascular anatomy, gated images
may be required and may be challenging to interpret in the setting of atrial fibrillation.

Homogeneous contrast admixture in the left atrium permits use of endocardial views. This
may be challenging in the right atrium due to the inflow of noncontrast-enhanced venous
return.

The assessment of the left atrial appendage for thrombus is limited by apparent filling
defects caused by the lack of contrast filling due to the complexity of the left
atrial appendage as well as decreased flow velocities in the left atrium and left atrial
appendage.

167

168

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

In the assessment of atrial masses, it is essential to define involvement of atrial masses


regarding the atrial chambers and atrial myocardium. Additionally, involvement of the pericardium, mediastinum, and vasculature connected to the atria requires thorough analysis.

Prominence of normal atrial structures such as the crista terminalis, network of Chiari, and
the Coumadin ridge can be mistaken for atrial masses.

The focus of coronary CT has centered on visualization


of the coronary arteries. This technology also provides
important diagnostic information for assessment of the
atria as well as the vascular connections to the atria.
The vascular connections to the atria are potential conduits for passage of catheters and leads important to
pacemaker and implantable cardiac defibrillator placement (systemic venous connections), resynchronization
therapy and percutaneous mitral valve annuloplasty (coronary venous connections), and ablation procedures
including atrial fibrillation ablation (pulmonary veins).

Comprehensive assessment of these structures as well


as the atria should be routinely performed as a component of analysis of coronary CT studies.

ATRIAL A NATOMY
There are special considerations regarding imaging
of the atria and their vascular connections. Analysis of
the atria and their vascular connections include twodimensional images, three-dimensional volumetric reconstructions, and endovascular images (Figs. 15-1 to 15-7).

n Figure 15-1 Serial two-dimensional axial views showing cranial to caudal slices of the atria. The series demonstrates the more cranial
appearance of the left atrium in relation to the right atrium. A, The left atrial appendage (upper arrow) and left upper pulmonary vein (lower
arrow) are visualized. Special attention to localization of the left atrial appendage needs to be paid when defining the field of view for acquisition
of images. B, The right atrial appendage (upper arrow) and right upper pulmonary vein (lower arrow) are seen. C, The right upper and lower
pulmonary veins (white arrows) and left lower pulmonary vein (black arrow) are seen. D and E, The atrial septum is seen on serial views and is
intact (white arrows). Note the difference in contrast between the right atrium and left atrium. The contrast injection protocol determines the
degree of contrast enhancement of these structures and choice of protocol depends on the indication for the study. F, The coronary sinus os is
seen on the most caudal slice and is normal in size, typically approximately 1 cm (black arrow).

Chapter 15

n Figure 15-2 Maximum intensity projection view of the left


atrium shows four pulmonary vein trunks and the left atrial
appendage. Normal pulmonary vein anatomy includes a wide range
of normal variations in the precise location and pattern of
branching.

Coronary Veins, Systemic Veins, and Atria

Determination of the field of view must take into account


that the left atrial appendage is usually the most cranial
cardiac structure, with the left atrium more cranial than
the right atrium. In cases in which anomalous vascular
structures are of concern, the field of view must be large
enough to encompass these structures and contrast protocols must be used that ensure visualization of venous and
arterial anatomy. With regard to endovascular imaging,
homogeneous contrast admixture in the left atrium allows
endocardial views. Endocardial reconstructions may be
challenging in the right atrium due to the inflow of noncontrast-enhanced venous return and saline bolus chasers
frequently used to enhance left heart visualization. The
assessment of the left atrial appendage for thrombus is limited by filling defects caused by heterogeneous and delayed
contrast filling due to the complexity of the left atrial
appendage and decreased flow velocities in the left atrium
and left atrial appendage.
As three-dimensional characterization of the atria and
vascular connections to the atria has become increasingly important for procedural facilitation, comprehensive analysis of these structures requires a systematic
approach. This should start with an assessment of serial

Posterior View

LAA

n Figure 15-3 Three-dimensional


volume-rendered views showing the
posterior left atrium with four
pulmonary vein trunks. Detailed
assessment, though, requires
definition of the pulmonary vein os
from an endovascular view and
measurement of en face twodimensional images of the pulmonary
vein/atrial interface. LAA, left atrial
appendage.

Inferior View

Superior View
LAA

169

170

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

n Figure 15-4 A, Endovascular view of the left atrium demonstrating the left upper and left lower
pulmonary veins (black arrows), Coumadin ridge and os of the left atrial appendage (white arrow).
B, A two-dimensional axial slice shows the perspective for the endovascular image in A (black arrow).

axial slices for overall review of anatomy. Oblique views


provide precise measurement of the pulmonary vein
ostia and visualization of the ostia en face. Threedimensional reconstructions allow assessment of the
pulmonary veins, coronary venous structures, volumetric
quantification of the atria, and the relationships of these
structures to thoracic structures. Endovascular views

n Figure 15-5 Two-dimensional oblique views of the left atrial


appendage (white arrow) revealing the complexity of the tubelike
structure and pectinate muscles. The assessment of a left atrial
appendage for thrombus is limited by filling defects caused by lack
of contrast filling due to the complexity of the left atrial
appendage as well as decreased flow velocities in the left atrium and
left atrial appendage. Delayed images, obtained several minutes
after the initial first-pass scan, can help to differentiate thrombi
from incomplete filling of the appendage by contrast.

facilitate assessment of the complexity of the pulmonary


vein ostia. For atrial fibrillation ablation, ungated
images can be used to decrease the radiation dose from
CT data acquisition. If the study is also being performed
to assess coronary vascular anatomy, gated images may
be required and may be challenging to interpret in the
setting of atrial fibrillation due to the irregularity and
frequently rapid rate of ventricular response.
The ability to analyze the three-dimensional data
cube created by CT angiography allows reconstruction
of atrial anatomy important for electrophysiology procedures such as atrial fibrillation ablation. The integration
of catheter-generated electroanatomic maps with CT
angiography reconstruction of the left atrium permits
catheter guidance and electrophysiologic mapping to
be visualized on a three-dimensional endovascular view
of the left atrium. Electroanatomic mapping with CT
image integration allows verification of the location of
the pulmonary vein os before placement of ablation
lesions to avoid pulmonary vein stenosis as a late complication of the procedure. The relationship of the atria to
other structures including the aorta, esophagus, and
bronchi are important to avoid procedural complications
related to these structures. The pulmonary vein map also
serves as a template for follow-up studies to detect
subsequent development of pulmonary vein stenoses.
This technique has led to an increase in procedural success and a decrease in incidence of postprocedural pulmonary vein stenoses.

CORONARY VENOUS SYSTEM


Renewed interest in the coronary venous system relates
to its use in clinical cardiac interventions, including
venous access to the posterior septum and left atrium

Chapter 15

Coronary Veins, Systemic Veins, and Atria

171

Left Atrium

Pulmonary
Vein
n Figure 15-6 A, Relationship of
the thin wall of the posterior left
atrium/pulmonary vein to the aorta
and esophagus is demonstrated on a
two-dimensional axial view. These
relationships are important to left
atrial ablation procedures to avoid
atrial/aortic and atrial/esophageal
complications. B, Relationship of
the posterior left atrium and left
lower pulmonary vein to the aorta
demonstrated on three-dimensional
volume-rendered views

Esophagus
Aorta

Aorta

Aorta

Left Atrium

Posterior View

for electrophysiologic mapping and ablation procedures,


venous access to left ventricular epicardium for left ventricular pacing in cardiac resynchronization therapy,
catheter access for percutaneous mitral annuloplasty,
and the regional delivery of therapeutic agents such as
cardioprotective drugs, cells, or gene vectors. Detailed
knowledge of the epicardial venous anatomy is necessary
for successful catheterization of the coronary sinus os
and branch veins.
The course of the anterior interventricular vein is
similar to that of the adjacent left anterior descending
artery as it runs in the interventricular sulcus toward
the base of the heart. At the base of the heart, it turns
laterally away from the left anterior descending artery

Left Atrium

Lateral View

Aorta

Left Atrium

Superior View

toward the circumflex artery in the left atrioventricular


groove to become the great cardiac vein and lies adjacent to the circumflex coronary artery. The great cardiac
vein usually receives tributaries from the left ventricular
surface via the anterior interventricular vein, a left marginal vein (similar in position to a marginal branch of
the circumflex artery), and a left posterior vein. Inferiorly in the atrioventricular groove, the great cardiac vein
drains into the coronary sinus. The coronary sinus
courses from the valve of the great cardiac vein to the
ostium of the coronary sinus at the right atrium. The
coronary sinus opens into the right atrium posteromedially through the highly variable remnant Thebesian
valve, which may present an obstruction to selective

172

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

n Figure 15-7 Three-dimensional electroanatomic mapping with image integration for atrial fibrillation
ablation. A, Three-dimensional electroanatomic map with image integration demonstrating an
endovascular view of the right pulmonary veins with radiofrequency ablation lesions (red spheres).
Superimposed on three-dimensional computed tomography (CT) volume-rendered images of the left
atrium, the lesion pattern demonstrates encircling lesions around the pulmonary veins at the atrial level
rather than in the pulmonary veins. B, Three-dimensional electroanatomic map with image integration
demonstrating an endovascular view of the left pulmonary veins with radiofrequency ablation lesions
(red spheres) superimposed on three-dimensional volume-rendered CT images of the left atrium with
lesion pattern demonstrating encircling lesions around the pulmonary veins at the atrial level. C and D,
Three-dimensional electroanatomic map with image integration with the atria made more transparent
demonstrating radiofrequency lesions (red spheres)

Chapter 15
Pulmonary
Arteries

Aorta
Left Atrium
Great Cardiac Vein
Circumflex
Coronary
Artery
Marginal Vein
Anterior
Interventricular
Vein

Left Ventricle

Coronary Veins, Systemic Veins, and Atria

173

cannulation of the coronary sinus. The middle cardiac


vein runs in the posterior interventricular groove, often
alongside the posterior descending artery branch, and
usually drains directly into the coronary sinus. Venous
drainage of the right ventricle is via the small cardiac
vein and its tributaries directly into the right atrium.
Coronary venous anatomy is variable in structure and
course in relation to the atria, atrioventricular annulus,
and coronary arteries (Figs. 15-8 to 15-10). The threedimensional relationship between the coronary arteries
and coronary veins is variable with regard to whether
the vein or artery is closer to the epicardium in areas
of overlap. The three-dimensional relationships between
veins, arteries, and epicardium are of great importance
for planning and facilitation of procedures.

n Figure 15-8 Three-dimensional volume-rendered view that


demonstrates the great cardiac vein coursing the atrioventricular
groove giving off marginal and anterior interventricular branches.
The circumflex coronary artery is seen medial and slightly inferior
to the great cardiac vein. The coronary sinus/great cardiac vein
course at the level of the atrioventricular groove.

A
Coronary Sinus

Left Atrium

Great Cardiac Vein

Posterolateral Vein
Lateral Vein

Left Ventricle

B
n Figure 15-9 A, Serial three-dimensional views demonstrate the coronary venous system as the heart is rotated posteriorly. Note that compared
with the image in Figure 15-8, the coronary sinus/great cardiac vein course higher than the atrioventricular groove at the atrial level. Several
large venous branches are seen to course along the lateral aspect of the ventricular myocardium. The three-dimensional relationship between
the coronary arteries, coronary veins, and epicardium is visualized. B, Three-dimensional reconstructions reveal the relationship between the
coronary arteries, coronary veins, and epicardium. Left, The coronary venous system with other structures edited out. Middle, The coronary
venous system (highlighted in red) and coronary arteries (pink). Right, Complete three-dimensional visualization of coronary arteries and veins
in relation to the cardiac chambers.
Continued

CX

LAD
RCA

CX

LAD

n Figure 15-9contd C, An axial two-dimensional image demonstrates the takeoff of the coronary sinus (white arrow) from the right atrium.
D, The patient with this coronary venous anatomy also demonstrated anomalous coronary arteries with the left anterior descending coronary artery
arising just anterior and cranial to the right coronary artery from a separate ostium off the right coronary cusp and giving off a conus branch coursing
anterior to the right ventricular outflow tract. The diminutive left anterior descending coronary artery courses intramyocardially via a trans-septal
course and proceeds to supply the septum but does not reach the left ventricular apex. The circumflex coronary artery arises off the right coronary artery
and takes a retroaortic course terminating in obtuse marginal branches, but does not extend to the atrioventricular groove. The right coronary
artery is a dominant large caliber vessel that gives off a posterior descending coronary artery and several large posterolateral branches, which supply
the majority of the lateral wall. CX, circumflex coronary artery; LAD, left anterior descending coronary artery; RCA, right coronary artery.

RV
1

LV
RA
Thebesian Valve

CS

C
n Figure 15-10 A, Serial axial images at the coronary sinus os level demonstrating a prominent Thebesian valve on all slices. CS, coronary sinus;
LV, left ventricle; RA, right atrium; RV, right ventricle. (From Shinbane JS, Girsky MJ, Mao S, et al: Thebesian valve imaging with electron beam CT
angiography: Implications for resynchronization therapy. Pacing Clin Electrophysiol 27:15661567, 2004, with permission.). B, A volume-rendered
image of the coronary sinus and branch vessels is shown. The image also demonstrates a circumflex marginal branch. C, Endocardial views from
right atrium through coronary sinus os visualizing the prominent Thebesian valve, which almost completely covers coronary sinus os lumen.

174

Chapter 15

Coronary Veins, Systemic Veins, and Atria

ANOMALOUS VENOUS
CO NNECTIO NS

Case 1

Partial Anomalous Pulmonary Venous Return

A 70-year-old woman presented with shortness of breath, presumed pulmonary


Mycobacterium avium intracellulare complex, and a history of coronary artery bypass
surgery (Fig. 15-11).

C
n Figure 15-11 A, Axial computed tomography image demonstrates an abnormal vessel (white arrow) to
the left of the aorta, in a location in the mediastinum where large venous vessels are not normally seen.
This vessel is an anomalous left upper pulmonary vein. B, A curved multiplanar reformatted view
demonstrates the full course of the anomalous left upper lobe pulmonary vein (white arrow) as it joins the
left brachiocephalic vein. C, A volume-rendered reconstruction of the chest, with the anterior chest
wall and mediastinum cut away, shows the three-dimensional anatomy of the anomalous left upper
pulmonary vein joining the brachiocephalic vein (white arrow).

175

176

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 2

Scimitar Syndrome

A 29-year-old man presented with symptoms of dyspnea, palpitations, chest pain,


and peripheral edema. Physical examination demonstrated jugular venous distention,
a left parasternal lift, a soft systolic ejection murmur over the pulmonic area,
hepatomegaly, ascites, and peripheral edema (Fig. 15-12).

RV

Pulmonary Vein
Pulmonary Artery
RA

CS
IVC

PV

C
n Figure 15-12 A, A curved multiplanar reformatted view demonstrates an anomalous right pulmonary
vein (white arrow, left), which joins the inferior vena cava. A dilated main pulmonary artery (white arrow,
right) is also seen. B, An axial two-dimensional view demonstrates an anomalous right pulmonary vein (PV)
that joins the inferior vena cava (IVC). Dilation of the right atrium (RA), coronary sinus os (CS), and right
ventricle (RV) are noted. C, A three-dimensional reconstruction demonstrates the anomalous right
pulmonary vein (white arrow) draining into the inferior vena cava.

Chapter 15

Case 3

Coronary Veins, Systemic Veins, and Atria

Total Anomalous Pulmonary Venous Return

A 25-year-old man presented with the chief symptoms of fatigue, dyspnea, and mild
cyanosis (Fig. 15-13).

n Figure 15-13 A, An axial two-dimensional image demonstrates a large secundum atrial septal defect
(black arrow). The confluence of right and left pulmonary venous return is seen (white arrows).
B, An axial two-dimensional image showing the confluence of left pulmonary veins (white arrow) coursing
to the right hemithorax. C, A coronal thick-slab maximum intensity projection image shows the
confluence of the right (white arrow) and left (black arrow) pulmonary veins. D, A coronal thick maximum
intensity projection demonstrates pulmonary venous return to the right atrium (black arrow).

177

178

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 4

Persistent Left Superior Vena Cava

A 56-year-old woman presented for evaluation for fatigue with the finding on a
routine chest x-ray of a widening of the mediastinal shadow. Coronary CT
angiography showed the persistent left superior vena cava in addition to the normal
right superior vena cava. This left superior vena cava drained into the right atrium
via the coronary sinus. The physiology was normal, and there was no hemodynamic
compromise (Fig. 15-14).

Subclavian Vein

Superior Vena Cava

Right Atrium

n Figure 15-14 A, Axial computed tomography demonstrates a persistent left superior vena cava (white arrow) to the left of the aorta.
B, A curved multiplanar reformatted view demonstrates the persistent left superior vena cava (white arrow) and the right superior vena cava
(black arrow). C, A volume-rendered reconstruction demonstrates the persistent left superior vena cava (white arrow) and the right superior vena
cava (black arrow). D, For comparison purposes, this image shows a volume-rendered reconstruction from a patient with a normal and
patent right superior vena cava. Normal venous anatomy is important to procedures involving access to the heart via a subclavian approach.

COMMENTS
Anomalies of venous return to the atria occur in a variety of forms. Commonly, partial anomalous pulmonary
venous return occurs in the setting of a sinus venosus

atrial septal defect. In partial anomalous pulmonary


venous returns one or several pulmonary veins return
to the right atrium, and the remainder of the pulmonary
venous flow returns, normally to the left atrium. Partial
anomalous pulmonary venous return is twice as common

Chapter 15

from the right lung than from the left lung. Partial anomalous pulmonary venous return can involve a wide variety
of connections, including right pulmonary veins draining
into the inferior vena cava, left pulmonary veins draining
into the innominate vein, the coronary sinus, and, rarely,
the cavae, right atrium, or left subclavian vein.
Scimitar syndrome, or pulmonary venolobar syndrome,
is characterized by abnormal right-sided pulmonary
venous drainage into the inferior vena cava and malformation and/or hypoplasia of the right lung, with abnormal
arterial supply of the right lung from the descending aorta.
Pulmonary venous return to the right side of the heart
causes right atrial and ventricular dilation with possible
sequelae including arrhythmias, right-sided heart failure,
and, rarely, development of pulmonary hypertension.
Total anomalous pulmonary venous return is characterized by the absence of direct pulmonary venous
drainage into the left atrium. In this entity, the pulmonary veins may drain into various venous structures
above or below the diaphragm. Connections above the
diaphragm may include the right atrium, coronary sinus,
or superior vena cava via a vertical vein. Alternatively,
when the pulmonary veins drain below the diaphragm,
they may join into a descending vein that enters the inferior vena cava or one of its larger tributaries, often via
the ductus venosus. Because the ductus venosus closes
soon after birth, obstruction to the pulmonary venous

179

Coronary Veins, Systemic Veins, and Atria

return may develop early. Rarely, the drainage may be


mixed, with some veins draining above the diaphragm
and others below it. In total anomalous pulmonary
venous return, mixing of oxygenated and deoxygenated
blood occurs before or at the level of the right atrium.
The right atrium, right ventricle, and the pulmonary
artery are generally enlarged, whereas the left atrium
and ventricle may remain normal or decreased in size.
The clinical presentation of total anomalous pulmonary
venous return depends on the presence or absence of
obstruction of the pulmonary venous channels.
Persistent left superior vena cava is a relatively rare
vascular anomaly. It is, however, the most common variation in the thoracic venous system. Failure of obliteration of the left anterior cardinal vein results in the
persistence of the left superior vena cava. It is normally
asymptomatic and is often detected during or after
placement of a pulmonary artery catheter or pacemaker
leads through the left internal jugular or subclavian
venous routes. The prevalence is estimated to be
approximately 0.3% in individuals with a normal heart
and 4.5% in individuals with congenital heart disease.
The importance of a persistent left superior vena cava
lies in a greater prevalence of other associated congenital
cardiovascular defects and significant incidence of
rhythm disturbances.

ATRIAL SEPTAL D EFECTS


Case 5

Ostium Secundum Atrial Septal Defect

A 37-year-old woman presented with exertional fatigue and dyspnea. On her chest
x-ray, the pulmonary artery was prominent, and pulmonary vascular markings were
increased in the lung fields (Fig. 15-15).

LA

RA

RV
RA

B
LA

LV

A
n Figure 15-15 Axial (A) and sagittal (B) images showing a secundum atrial septal defect with left-to-right atrial shunting and right atrial and
right ventricular enlargement. LV, left ventricle; RA, right atrium; RV, right ventricle.

180

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 6

Ostium Secundum Atrial Septal Defect

A patient presented with palpitations and chest and arm pain. A CT angiogram
was ordered for consideration for percutaneous closure of an atrial septal defect
(Fig. 15-16).

RV
RV

RA
LV
LV

RA

LA

LA

D
C
n Figure 15-16 A, An ostium secundum atrial septal defect is present with evidence of right atrial and
right ventricular enlargement. Superior and inferior rims of atrial septum are present and important for
assessment of the feasibility of percutaneous closure of the atrial septal defect. B, Atrial systole
demonstrating left-to-right flow across the atrial septal defect. C, Endovascular view of the atrial septal
defect from the right atrium to the left atrium. D, Measurement of the dimensions of the ovoid atrial
septal defect viewed en face (arrow). LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

Chapter 15

Case 7

Coronary Veins, Systemic Veins, and Atria

181

Sinus Venosus Atrial Septal Defect

A 25-year-old man presented with fatigability, dyspnea, palpitations, and syncope.


There was dilation of the superior vena cava on his chest x-ray (Fig. 15-17).

RV
LV

RA

LA
n Figure 15-17 A sinus venosus atrial septal defect is seen on a
two-dimensional axial view with evidence of right atrial and right
ventricular enlargement. LA, left atrium; LV, left ventricle; RA, right
atrium; RV, right ventricle.

Case 8

Patent Foramen Ovale

A 53-year-old woman presented with pulmonary hypertension of unknown cause


(Fig. 15-18).

n Figure 15-18 A two-dimensional axial image demonstrates a jet


of contrast (arrow) exiting the relatively more densely opacified right
atrium and entering the relatively less opacified left atrium,
consistent with a patent foramen ovale in the setting of elevated right
atrial and right ventricular pressures due to pulmonary hypertension.
The patent foramen ovale was seen on transthoracic
echocardiography. The finding of the patent foramen ovale was
incidental, and a cause of pulmonary hypertension was not identified.

CO MMENTS
Atrial septal defects and anomalies associated with these
defects can be characterized by cardiovascular CT.

The size of the atria, right ventricle, and pulmonary


arteries are important details in the assessment of
studies demonstrating atrial septal defects. Sinus venosus defects occur in the upper portion of the septum
in close proximity to the superior vena cava and can be
characterized with additional assessment for anomalies
of pulmonary venous return. Secundum atrial septal
defects occur in the midportion of the septum involving
the fossa ovalis. Care should be taken to closely evaluate
areas where the atrial septum can be normally thin,
such as the fossa ovalis. In this location, a false-positive
diagnosis of an atrial septal defect can be made.
Measurements of secundum defect size as well as
characterization of the superior and inferior rim of septum are important to the assessment for decisions
related to the use and sizing of percutaneous closure
devices. Ostium primum atrial septal defects occur in
close proximity to the atrioventricular valves and often
occur with atrioventricular valve abnormalities. A patent foramen ovale can be visualized by cardiovascular
CT and is important to facilitate trans-septal catheter
approaches as part of atrial fibrillation ablation procedures. Atrial septal aneurysms can also be diagnosed
on cine images showing hypermobile atrial septal
tissue.

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ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

ATRIAL MASSES
Case 9

Atrial Thrombus

A 38-year-old woman with gastric cancer and a liver injury at the time of resection of
her gastric mass presented with a mass in the right atrium, noted on the
echocardiogram (Fig. 15-19).

C
n Figure 15-19 A, The right atrial thrombus is shown as a filling defect (white arrow) surrounded by
contrast. B, After appropriate anticoagulation, the right atrial mass has resolved. C, A coronary magnetic
resonance image shows the mass to be dark on all sequences, consistent with thrombus (black arrow).

Case 10

Atrial Myxoma

A 68-year-old man with colorectal cancer was shown to have a left atrial mass that
persisted on serial CT scans (Fig. 15-20).

Chapter 15

Coronary Veins, Systemic Veins, and Atria

183

C
n Figure 15-20 A, The left atrial myxoma attached to the septum is visualized on a two-dimensional
view. B, A three-dimensional reconstruction is edited to view the endocardial mass. C, After contrast
administration, the left atrial mass is more apparent (black arrow).

Case 11

Inferior Vena Cava and Right Atrial Mass

A 67-year-old man presented with cirrhosis and increasing abdominal girth (Fig. 15-21).

n Figure 15-21 A, An axial two-dimensional image demonstrated a mass in the dome of the diaphragm (white arrow) with extension into the
inferior vena cava (black arrow). B, A coronal image further delineates tumor extension (black arrow) into the inferior vena cava and right atrium.
Continued

184

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

C
n Figure 15-21contd C, A sagittal image further
delineates tumor extension (black arrow) into the inferior
vena cava and right atrium.

Case 12

Inferior Vena Cava and Right Atrial Mass

A 34-year-old man presented with a 1-year history of mixed germ cell tumor
(teratoma) and known metastatic disease to retroperitoneal lymph nodes
(Fig. 15-22).

n Figure 15-22 A, Axial thick-slab maximum intensity projection images demonstrate retroperitoneal lymphadenopathy with left renal vein
invasion (black arrow). B, Tumor invasion is seen in the inferior vena cava (black arrow).
Continued

Chapter 15

Coronary Veins, Systemic Veins, and Atria

D
n Figure 15-22contd C, Tumor invasion extends into the right atrium (black arrow). D, Coronal curved multiplanar reformatted
image demonstrates retroperitoneal lymphadenopathy (white arrows) and invasion of tumor into the inferior vena cava and right
atrium (black arrow).

Case 13

Bilateral Atrial Thrombi

A 58-year-old man presented with chest pain and shortness of breath (Fig. 15-23).

n Figure 15-23 A, A two-dimensional axial view demonstrates thrombi in the right and left atrial
appendages (white arrows). Bilateral pleural effusions are also noted. Pulmonary embolus was ruled out in
this study. B, A two-dimensional axial view shows an additional left ventricular thrombus (white arrow).
Artifact is seen from a right ventricular pacing lead. Thrombi in multiple locations heightens concerns
regarding a hypercoagulable state.

185

186

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

COMMENTS
Atrial masses frequently pose a diagnostic dilemma.
Because biopsy of a cardiac mass is a difficult undertaking with inherently high morbidity and mortality and
therefore is seldom performed clinically, it is necessary
to be familiar with characteristic imaging findings of
benign and malignant cardiac masses to narrow diagnostic considerations.
The most common cause of a cardiac mass is metastatic cancer. Metastases to the heart have several common presentations. First, a tumor may present as an
intraluminal mass invading the atria from the primary
site of origin, usually through the inferior vena cava,
and has been frequently reported in hepatocellular carcinoma, renal cell carcinoma, adrenal cortical carcinoma,
and other tumors of the retroperitoneum. These situations seldom present a diagnostic dilemma because the
mass in the right atrium is usually contiguous with the
primary mass. Similarly, tumors of the lung and mediastinum, most commonly bronchogenic carcinoma, may
spread into the left atrium via the pulmonary veins.
Additionally, metastases to the heart may present as
hematogenous metastases to the myocardium. In this
case, the appearance is usually of a broad-based mass.
A less frequent presentation of disease is direct spread
to the heart from adjacent structures, such as invasion
from a primary mediastinal tumor. In these cases, the
epicenter of the mediastinal mass is commonly seen outside of the heart. These masses may also be more easily
accessible for biopsy than cardiac metastases.
There are numerous causes of benign cardiac masses.
The most common benign cardiac mass is an atrial myxoma, which is frequently found in the left atrium (80%
of cases) and less commonly in the right atrium (20%
of cases). Other relatively commonly encountered
benign entities include the network of Chiari and other
remnants of normal structures including a prominent
crista terminalis. A prominent Coumadin ridge in the
left atrium can also be mistaken for a mass. In general,
benign masses are pedunculated and present as intraluminal masses. This is in contradistinction to malignant
cardiac masses, which are usually broad based and intramural. A notable exception to this rule is in pediatric
patients in whom benign intramural masses may occur
including rhabdomyomas and cardiac fibromas.
Thrombi can occur in the atria in a variety of settings. The left atrial appendage is often the site of
thrombus in the setting of atrial fibrillation and atrial
flutter with associated large atria and low atrial appendage velocities. With CT angiography, filling defects in
the left atrial appendage can be caused by lack of contrast filling due to the tubelike structure of the appendage and decreased flow velocities causing artifacts that
mimic thrombi. Atrial thrombi can occur in the right
atrial appendage or in the chambers themselves,

especially in the setting of significant valvular disease,


such as mitral and tricuspid stenoses. Atrial thrombi can
occur as extensions of thrombi from vascular structures
such as the superior vena cava or inferior vena cava.
Thrombi can also occur on foreign bodies in the atria
including pacing leads and catheters. Stigmata of these
thrombi include pulmonary embolus and systemic
embolus.

SUGGESTED READINGS
Aboulhosn J, French WJ, Buljubasic N, et al: Electron beam angiography for the evaluation of percutaneous atrial septal defect closure,
Catheter Cardiovasc Interv 65:565568, 2005.
Dourado R, Abecasis J, Anjos R: Evaluation of scimitar syndrome by
multislice computed tomography, Cardiol Young 18:539540, 2008.
Gottlieb I, Pinheiro A, Brinker JA, et al: Diagnostic accuracy of arterial
phase 64-slice multidetector CT angiography for left atrial appendage thrombus in patients undergoing atrial fibrillation ablation, J
Cardiovasc Electrophysiol 19:247251, 2008.
Hoffmeister PS, Chaudhry GM, Mendel J, et al: Evaluation of left
atrial and posterior mediastinal anatomy by multidetector helical
computed tomography imaging: relevance to ablation, J Interv Card
Electrophysiol 18:217223, 2007.
Jongbloed MR, Bax JJ, Lamb HJ, et al: Multislice computed tomography versus intracardiac echocardiography to evaluate the pulmonary veins before radiofrequency catheter ablation of atrial
fibrillation: A head-to-head comparison, J Am Coll Cardiol
45:343350, 2005.
Jongbloed MR, Dirksen MS, Bax JJ, et al: Atrial fibrillation: Multidetector row CTof pulmonary vein anatomy prior to radiofrequency
catheter ablationinitial experience, Radiology 234:702709, 2005.
Jongbloed MR, Lamb HJ, Bax JJ, et al: Noninvasive visualization of
the cardiac venous system using multislice computed tomography,
J Am Coll Cardiol 45:749753, 2005.
Kim TH, Kim YM, Suh CH, et al: Helical CT angiography and threedimensional reconstruction of total anomalous pulmonary venous
connections in neonates and infants, AJR Am J Roentgenol 175:
13811386, 2000.
Kim YH, Marom EM, Herndon JE 2nd, et al: Pulmonary vein diameter, cross-sectional area, and shape: CTanalysis, Radiology 235:4349,
2005.
Kistler PM, Rajappan K, Jahngir M, et al: The impact of CT image
integration into an electroanatomic mapping system on clinical outcomes of catheter ablation of atrial fibrillation, J Cardiovasc Electrophysiol 17:10931101, 2006.
Kucukarslan N, Kirilmaz A, Ulusoy E, et al: Eleven-year experience in
diagnosis and surgical therapy of right atrial masses, J Card Surg
22:3942, 2007.
Lembcke A, Razek V, Kivelitz D, et al: Sinus venosus atrial septal
defect with partial anomalous pulmonary venous return: Diagnosis
with 64-slice spiral computed tomography at low radiation dose,
J Pediatr Surg 43:410411, 2008.
Malchano ZJ, Neuzil P, Cury RC, et al: Integration of cardiac CT/MR
imaging with three-dimensional electroanatomical mapping to guide
catheter manipulation in the left atrium: Implications for catheter
ablation of atrial fibrillation, J Cardiovasc Electrophysiol 17:
12211229, 2006.
Mao S, Shinbane JS, Girsky MJ, et al: Coronary venous imaging
with electron beam computed tomographic angiography: Threedimensional mapping and relationship with coronary arteries,
Am Heart J 150:315322, 2005.
Martinek M, Nesser HJ, Aichinger J, et al: Impact of integration of
multislice computed tomography imaging into three-dimensional
electroanatomic mapping on clinical outcomes, safety, and efficacy
using radiofrequency ablation for atrial fibrillation, Pacing Clin, Electrophysiol 30:12151223, 2007.
Oral H, Pappone C, Chugh A, et al: Circumferential pulmonary-vein
ablation for chronic atrial fibrillation, N Engl J Med 354:934941,
2006.

Chapter 15
Saremi F, Pourzand L, Krishnan S, et al: Right atrial cavotricuspid
isthmus: Anatomic characterization with multi-detector row CT,
Radiology 247:658668, 2008.
Sra J, Narayan G, Krum D, et al: Computed tomography-fluoroscopy
image integration-guided catheter ablation of atrial fibrillation, J
Cardiovasc Electrophysiol 18:409414, 2007.
Van de Veire NR, Marsan NA, Schuijf JD, et al: Noninvasive imaging
of cardiac venous anatomy with 64-slice multi-slice computed

Coronary Veins, Systemic Veins, and Atria

187

tomography and noninvasive assessment of left ventricular dyssynchrony by 3-dimensional tissue synchronization imaging in patients
with heart failure scheduled for cardiac resynchronization therapy,
Am J Cardiol 101:10231029, 2008.
Williamson EE, Kirsch J, Araoz PA, et al: ECG-gated cardiac CTangiography using 64-MDCT for detection of patent foramen ovale,
AJR Am J Roentgenol 190:929933, 2008.

Chapter

16

Aortic Disease
Michael A. Bolen and Suhny Abbara

KEY POINTS
l

Typical computed tomography (CT)based upper limits of aortic diameter are 3.7 cm
(sinuses of Valsalva), 3.5 cm (ascending aorta at level of right pulmonary artery), 3.0 cm
(aortic arch), and 2.5 cm (descending segment).

Thoracic aortic aneurysm occurs when there is dilation of the aortic diameter of 50% or
more of normal value.

Aortic intramural hematoma represents hemorrhage into the medial layer of the aorta and
appears on CT as high-attenuation eccentric or concentric material on precontrast images
with lack of contrast enhancement.

Multidetector CT is the first-line imaging modality for most acute aortic dissection. Gated CT is
preferable for the ascending aorta to avoid false-positive diagnoses from aortic motion.

Penetrating atherosclerotic ulcer is suggested by focal intramural hematoma and displaced intimal calcification on a noncontrast study. Postcontrast images demonstrate a discrete, rounded
outpouching that may be accompanied by dissection, pseudoaneurysm, or hematoma.

Pseudo-coarctation can be differentiated from true coarctation by CT or magnetic resonance imaging (MRI), by identifying the high and elongated arch, with pseudo-kinking that
lacks luminal narrowing, and by the absence of enlarged collateral arteries.

Imaging features of infectious aortitis include saccular enlargement of the aorta with rapid
change, periaortic inflammation or hematoma, and a periaortic gas collection.

Imaging features that may be seen in noninfectious aortitis include wall thickening, caliber
change in the aorta and its large branches (increase or decrease in caliber), and aortic
regurgitation associated with aortic root dilation

188

Chapter 16

Case 1

Normal Anatomy and Common Variants

Knowledge of the normal aortic anatomy and its common variants permits optimal
interpretation of aortic CT (Fig. 16-1).

Left common carotid


artery
Brachiocephalic
artery
Ascending
aorta

Left subclavian
artery
Aortic arch

Sinotubular
junction
Right
coronary
artery

Left
main
coronary
artery

Descending
thoracic
aorta

Abdominal
aorta

n Figure 16-1 A, Normal aortic anatomy and nomenclature. The thoracic aorta can be partitioned into
three segments: the ascending aorta, the aortic arch, and the descending thoracic aorta. Typical aortic
dimension measurements are 3.7 cm or less (at the level of the sinuses of Valsalva), 3.5 cm (ascending aorta
at right pulmonary artery level), 3.0 cm (aortic arch), and 2.5 cm (descending thoracic aorta). The most
common branching pattern of the arch vessels is shown, including a brachiocephalic, left common carotid,
and left subclavian, but several variants are commonly recognized. B, Oblique sagittal maximum intensity
projection shows a two-vessel or bovine arch, with common trunk for brachiocephalic and left common
carotid arteries (arrow) and a separate ostium for the left subclavian artery. C, A four-vessel arch, with left
vertebral artery (indicated by arrow) arising directly from the aortic arch, is present on this three-dimensional
reconstruction. D, Sagittal oblique (candy cane) image of the aorta obtained from computed tomography
of the thorax performed on a 25-year-old woman without history of trauma or chest pain. A rounded contour
along the inner curvature of the aortic isthmus (arrow indicates location) is noted. Given the obtuse margins
of the contour, and benign clinical history, the findings are consistent with ductus diverticulum.

Aortic Disease

189

190

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

COMMENTS
The thoracic aorta has its origin at the annulus and
extends to the diaphragmatic hiatus. The thoracic aorta
may be partitioned into three segments: the ascending
aorta, the aortic arch, and the descending aorta.
The ascending aorta includes the aortic root and the
tubular ascending aorta. The aortic root is the most proximal portion of the thoracic aorta. The root is positioned
between the aortic annulus and the sinotubular junction
and is composed of the three sinuses of Valsalva (right,
left, and noncoronary). The normal aortic root diameter
is typically less than 3.9 cm. The tubular segment of the
ascending aorta extends from the sinotubular junction to
the brachiocephalic trunk. Approximately 2 to 3 cm of
the ascending aorta are intrapericardial. The normal
ascending aorta measures 3.5 cm or less at the level of
the right pulmonary artery, where reproducible measurements can be acquired on axial images. Generally, double
oblique planes in the aortic short axis are required for
diameter measurements. The left and right coronary
arteries are the only vessels branching off the ascending
aorta, arising from their respective sinuses of Valsalva.
The aortic arch passes from the proximal ostium of the
brachiocephalic trunk to the distal ostium of the left subclavian artery. This is followed by the isthmus, which is
attached to the ligamentum arteriosum. The aortic arch
is normally 3.0 cm or less, with the isthmus often slightly
smaller in diameter than the proximal descending aorta.

Case 2

Typically, there are three branches arising from the aortic


arch: the brachiocephalic trunk or artery (also referred to
as the innominate artery), the left common carotid artery,
and the left subclavian artery. Common variants include
left vertebral artery arising directly from the arch (rather
than from the left subclavian artery), as well as the bovine
arch, which represents a two-vessel arch, where a common trunk for the brachiocephalic and left common
carotid is noted. Although the term bovine arch is commonly used for this configuration, it is not actually the
anatomy noted in cattle, which is a single brachiocephalic
trunk that divides into the bilateral subclavian arteries and
a bicarotid trunk. Another common normal variant is the
ductus diverticulum, which represents the residual of the
ductus arteriosum. This often appears as a focal bulge
along the inner curvature of the isthmus and may resemble a pseudo-aneurysm from traumatic aortic transection.
The ductus diverticulum is characterized by smooth contour and obtuse angles. This must be distinguished from
aortic transection, which more commonly creates acute
angles with the aortic wall.
The descending thoracic aorta passes from the aortic
isthmus to the diaphragmatic crura. Normal diameter of
the descending thoracic aorta is 2.5 cm or less. Vessels
branching from the descending thoracic aorta supply intrathoracic muscles and organs and include bronchial, spinal,
intercostal, and superior phrenic arteries, in addition to
smaller branches supplying the esophagus and pericardium.

Sinus of Valsalva Aneurysm

A 38-year-old man with arthrogryposis and retinal detachment presented with


suspected sinus of Valsalva aneurysms detected on echocardiogram. The patient was
referred for assessment of the aortic root with electrocardiographically gated CT
(Fig. 16-2).

COMMENTS
Congenital sinus of Valsalva aneurysms represent dilation of a sinus of Valsalva caused by a separation
between the media of the aorta and the annulus fibrosus.
They typically involve only a single coronary sinus (versus multiple as in this case). Deficient elastic tissue, as
well as abnormal development of the bulbus cordis, is
thought to be the cause of this deformity. In addition,
a number of disease processes that affect the aortic root,
such as cystic medial necrosis, endocarditis, and atherosclerotic aneurysms, can also cause a sinus of Valsalva
aneurysm, although multiple sinuses are typically
involved in these instances. The multiple sinuses
affected, in combination with the aneurysmal coronary
arteries, and deformed thoracic skeleton in the case presented above are suggestive of an underlying connective
tissue disorder in this patient.
Several complications can occur in cases of sinus of
Valsalva aneurysm. Rupture of the dilated sinus can lead
to a left-to-right intracardiac shunt with either the right

ventricle or the right atrium. Rupture into the pericardial space may cause tamponade. Sinus of Valsalva
aneurysms that have not ruptured are often asymptomatic and detected incidentally on echocardiography.
The majority of ruptured sinus of Valsalva aneurysms
occur in the time period between puberty and 30 years,
and the rupture is often the first clinical presentation
of these patients. These aneurysms can uncommonly
present with endocarditis, starting at the edge of the
enlarged sinus. Last, obstruction of the left or right outflow tract can present with symptoms of palpitations or
syncope. Associated congenital abnormalities include
ventricular septal defect, aortic insufficiency, and coarctation of the aorta.
Multidetector CT provides specific advantages in the
assessment of sinus of Valsalva aneurysms including high
spatial resolution and postacquisition multiplanar reformatting for accurate and reproducible measurements
that can help guide therapy. Echocardiography is more
operator dependent and does not provide the same

Chapter 16

Aortic Disease

191

R
N
L

E
n Figure 16-2 Candy cane and coronal oblique (A) and multiplanar reformatted (B) images showing aneurysmal changes of the sinuses of
Valsalva (arrows). The aorta is otherwise normal, including a preserved sinotubular junction. A deformed thoracic cage is demonstrated
on the coronal image. C, True short axis multiplaner reformatted image of the aorta at level of the sinuses of Valsalva (N = noncoronary,
R = right, L = left) shows marked contour abnormality and aneurysmal dilation, most prominent in noncoronary sinus. Maximum root
diameter is greater than 7 cm. The volumetric data sets provided by MDCT allow postacquisition multiplanar reformatting of images in any
plane, with accurate reproducible measurements of complex anatomical structures such as the aortic root. D and E, Curved multiplanar
reformatted images show aneurysmal dilation of the proximal left circumflex (indicated by two arrows), and left anterior descending coronary
arteries (single arrow). No areas of stenosis were present. Electrocardiographically gated multidetector CT allows concurrent assessment of
both the aorta and epicardial coronary arteries.

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ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

volumetric data set, making it less reproducible in


measuring the complex anatomy of the aortic root.
Magnetic resonance imaging is an additional imaging

Case 3

alternative that can provide an assessment of associated


aortic regurgitation or left-to-right shunts when rupture
occurs.

Ascending Aortic Aneurysm

A 76-year-old woman with no known cardiac history presented with newly diagnosed
congestive heart failure and a murmur suggestive of aortic insufficiency. An
echocardiogram showed a significantly dilated aortic root. A cardiovascular CT was
performed to further evaluate this finding (Fig. 16-3).

aAo

aAo

LV

n Figure 16-3 A, Axial


postcontrast computed tomography
image at mid thoracic level shows
massive dilation of the ascending
aorta (aAo), with compression of
the left atrium between the enlarged
ascending aorta and tortuous
descending (#) aorta. B, Sagittal
oblique image shows a markedly
enlarged ascending aorta with
anterior margin of aorta in the
immediate retrosternal region.
LV, left ventricle. C, Volumetric
rendering demonstrates the severe
aneurysmal dilation of the
ascending aorta (arrow), which
tapers through the aortic arch.

Chapter 16

Aortic Disease

193

CO MMENTS
A thoracic aortic aneurysm occurs when there is dilation
of greater than 50% of normal diameter of the aorta.
Thoracic aneurysms may be categorized by the region
of the aorta involved: the ascending aorta, the arch, or
the descending thoracic aorta. A descending thoracic
aorta aneurysm may also extend into the abdominal
aorta, resulting in a thoracoabdominal aortic aneurysm.
This classification is important because the causative
factors, natural history, and treatment of thoracic aneurysm are different for each segment.
Aneurysms of the ascending aorta are commonly due
to cystic medial degeneration (also known as cystic
medial necrosis). This condition affects large arteries
and is characterized by a loss of elastic and muscle fibers
in the aortic media, with mucopolysaccharide accumulation, sometimes forming cystic spaces. These histologic
changes weaken the aortic wall, which leads to the formation of fusiform aneurysms. Aneurysms of this type
frequently affect the aortic root, causing annuloaortic
ectasia, which may in turn result in aortic insufficiency.
Changes most frequently involve the ascending aorta,
but occasionally the entire aorta may be affected. Cystic
medial degeneration is associated with many connective
tissue disorders and is noted in nearly all cases of Marfan
syndrome. It is unclear whether cystic medial degeneration exists in some cases as an independent idiopathic
disease process or represents a manifestation of different
connective tissue disease processes that also affect aortic
media. Syphilis was, at one time, a common cause of

Case 4

ascending thoracic aortic aneurysms, but has become


much less common due to antibiotic treatment during
the earlier stages of this infectious process.
Atherosclerosis is the most common cause of aneurysms of the descending thoracic aorta, which often originate just distal to the origin of the left subclavian artery.
These may be saccular or fusiform in morphology. The
pathophysiology of this process is thought to be similar
to abdominal aortic aneurysms, but has not been investigated in detail. In contrast, atherosclerosis is a less common cause of ascending aortic aneurysms. Aortic arch
aneurysms are often contiguous with aneurysms of the
ascending or descending aorta and, as such, are due to
cystic medial degeneration, atherosclerosis, or infection.
Infectious aortitis is an unusual cause of aortic aneurysms that may result in aortic dilation in either a fusiform or saccular aneurysm. This most commonly
occurs as a secondary process in an aneurysm that is
due to another etiology and in some cases may be attributed to direct spread from aortic valve endocarditis.
Imaging plays an important role in the identification
of aortic aneurysms, the follow-up of this condition, as
well as assessment of complications, including rupture
or dissection. Aortography has been the standard against
which other modalities were compared in the past; however, more recently, transesophageal echocardiography,
MRI, and CT have grown to more prominent roles in
this workup. This topic is also addressed in the discussion following Case 6.

Intramural Hematoma

A 72-year-old man with a previous myocardial infarction and hypertension


experienced sudden onset of lower substernal chest pain that radiated toward his
back and did not improve with sublingual nitroglycerin. Cardiac CT was performed
(Fig. 16-4).

CO MMENTS
Intramural hematomas are thought to represent a spontaneous hemorrhage of the vasa vasorum into the arterial medial layer. Unlike aortic dissections, there is
typically no intimal tear present. CT imaging protocols
typically include both pre- and postcontrast imaging to
best demonstrate the salient findings. Cardiac gating is
indicated when ascending aortic involvement is known
or suspected to avoid pulsation artifact, which can
mimic ascending aortic dissection flaps and can make
exclusion of intramural hematoma impossible. The CT
appearance of an intramural hematoma is concentric or
eccentric high-attenuation material, which is often best
demonstrated on precontrast images. Displaced intimal
calcification may be present. A hematoma should not

show postcontrast enhancement. It does not typically


spiral around the aorta, which can be seen in cases of
dissection.
Intramural hematomas can be classified according to
the Stanford system in which type A hematomas are
treated with surgery to protect against possible progression to dissection, rupture, or hemorrhage into pericardial, pleural, or mediastinal spaces. Some patients with
limited type A intramural hematoma may be managed
medically and followed with serial imaging. Type B
intramural hematomas (as in the sample cases presented
previously) are usually managed with medical treatment
and follow-up imaging and may either regress or, in
some cases, progress to dissection or aneurysm; thus,
serial imaging is indicated.

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ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

B
n Figure 16-4 A, Noncontrast axial computed tomography (CT) image at the level of the right
pulmonary artery. The wall of the descending thoracic aorta (two arrows) is abnormally thickened and high
in attenuation, consistent with intramural hematoma. B, Postcontrast axial CT image from same patient
again demonstrates an abnormal appearance of the descending thoracic aortic wall. The relatively high
attenuation of the hematoma is less obvious on postcontrast images (white arrows); however, quantitative
analysis revealed that the Hounsfield units (HU) were unchanged (70 HU on each study at this level)
between pre- and postcontrast images. This slice level is slightly different from a noncontrast image and
shows a small calcified intimal plaque (black arrow) at the luminal border.

Case 5

Aortic Dissection

A 66-year-old man with hypertension and a history of smoking presented with 3-day
history of vague chest pain. The pain became much more intense along with
radiation to the neck on the day of admission. He was diaphoretic, with shortness
of breath and blood pressure of 70/40 en route to the hospital (improved
with administration of fluid resuscitation). Cardiac CT was performed
(Fig. 16-5).

Chapter 16

C
n Figure 16-5 Axial postcontrast computed tomography image just caudal to the level of left subclavian
origin (A) shows the origin of the dissection flap (arrows). B, Several centimeters caudally, demonstrating a
normal ascending aorta and a dissection flap (black arrow) in the descending thoracic aorta as well as
mediastinal hemorrhage (white arrow) and pleural fluid. C, Three-dimensional volumetric image
demonstrates the dissection starting just distal to the left subclavian artery (short arrow) and extending into
the bilateral common iliac arteries (arrows).

Case 6

Aortic Dissection

A 59-year-old man with a history of tobacco and alcohol use and treated
hypertension experienced sharp chest pain. He initially attributed the pain to
indigestion; however, the intense pain persisted. An electrocardiogram revealed ST
depressions in the precordial leads and tachycardia. Nonelectrocardiographically
gated CT revealed a type A dissection. After hospital transfer, an
electrocardiographically gated CT was performed (Fig. 16-6).

Aortic Disease

195

196

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

C
n Figure 16-6 A, Axial image at the level of the great vessels shows a dissection flap that extends into
the left subclavian artery (arrows). B, The axial image at the level of the right pulmonary artery shows a
dissection flap in the ascending aorta (arrow), but not in the descending thoracic aorta. Note that the true
and false lumens show a similar level of contrast opacification. C, A coronal reformatted image from the
same patient shows the dissection flap extending into the left main coronary artery (arrow).

COMMENTS
Aortic dissection occurs when a laceration of the aortic
intima and inner portion of the media creates a false
lumen within the outer third of the media. This lumen
fills with blood, which may remain free flowing or
thrombose. Risk factors for aortic dissection include
chronic hypertension, aortic aneurysm, cardiovascular
surgery, Marfan syndrome, and a bicuspid aortic valve.
Dissection can involve any segment of the aorta. The
two predominant classifications are defined by dissection location and the extension of the intimal flap. The
classifications are DeBakey (type I, the intimal flap
involves the ascending and descending thoracic aorta;
type II, the flap is isolated to the ascending thoracic
aorta; type III, the flap involves only the descending
aorta), and the Stanford classification (type A, the intimal flap involves the ascending aorta and may or may

not extend to the descending aorta; type B, the dissection flap does not extend into the ascending aorta). Dissections that involve the ascending aorta are typically
considered surgical emergencies because the dissected
ascending aorta is vulnerable to rupture, which may lead
to hemopericardium, pericardial tamponade, and death.
The acute period of dissection has been defined as
the 14 days after dissection because this is the period
of highest morbidity and mortality. Mortality rates for
an untreated type A aortic dissection have been estimated at 1% to 2% per hour for the first 24 hours and
80% during the first 2 weeks. Prompt and accurate identification of a dissection and evaluation of the extent of
the dissection are critical in the management of this condition. Information obtained from physical examination
and clinical history is not sufficient because dissection
may mimic other acute conditions such as myocardial
ischemia and stroke.

Chapter 16

Imaging features of aortic dissection include detection of the intimal flap and entry/reentry sites, the presence and severity of aortic regurgitation, and patency of
flow in aortic branches. Distinguishing true and false
lumens is important for treatment planning in cases of
endovascular repair. Findings that suggest the false
lumen include linear low attenuation strands (thought
to represent residual media that have not completely
torn away during dissection). A false lumen typically
has a larger cross section compared with a true lumen
and a wedge-shaped area of hematoma that is at the
propagating edge of the false lumen, the beak sign. Frequently, the true lumen can be identified on postcontrast
studies by evaluating adjacent nondissected portions of
the aorta and following the contiguous portions of
lumen.
CT plays a prominent role in the diagnostic evaluation of aortic dissection. The International Registry of
Acute Aortic Dissection determined that CT was the
imaging modality of choice in most cases of suspected
aortic dissection, followed by transesophageal echocardiography, aortography, and MRI. The estimated sensitivity rates of these modalities in the detection of acute
aortic dissection is close to 100% for MRI, 93% for
CT, 88% for angiography, and 87% for transesophageal
echocardiography. However, the pace of improvement
of imaging techniques has made accurate comparison
of modalities difficult. Benefits of CT include acquiring

Case 7

Aortic Disease

197

volumetric data from thoracic inlet to the level of femoral arteries in seconds. Accurately identifying flap entry
and reentry sites is a challenge for all imaging modalities, but the submillimeter resolution of multidetector
CT is well suited to this task. Use of electrocardiographic gating techniques is indicated in cases in
which involvement of the aortic root is known or suspected. Initial scan without use of intravenous contrast is
helpful to assess for high-attenuation material in the false
lumen, which helps to differentiate from mural thrombus
associated with an aneurysm. In addition to axial images,
multiplanar reconstructions aid in providing an overall
assessment of the aortic dissection and its relationship to
branch vessels. Volume rendering offers benefits compared with thicker maximum intensity projection and
surface-shaded display for three-dimensional imaging
because it retains the variable luminal enhancement and
is more sensitive in identifying the flap. Pitfalls that may
mimic aortic dissection include cardiac and aortic motion
(pulsation artifact), poor contrast timing or rate of administration, aortic aneurysm with mural thrombus, and adjacent anatomic structures such as aortic branch vessels,
venous structures crossing over an artery, small amounts
of pericardial fluid adjacent to the aorta, and others. Many
artifacts and pitfalls may be avoided with use of a precontrast study, electrocardiographically gated arterial-phase
postcontrast images, and a delayed scan to assess for slow
flow in a false lumen.

Penetrating Atherosclerotic Ulcers

A 67-year-old woman with hypertension and hyperlipidemia presented with newonset back pain (Fig. 16-7).

CO MMENTS
A penetrating atherosclerotic ulcer (PAU) is thought to
occur when rupture of an atheromatous plaque disrupts
the elastic lamina, with variable extension into the
media. PAUs are most common in elderly patients with
hypertension and atherosclerotic disease. Extension of
the ulceration into the media may lead to an intramural
hematoma (although this does not always occur, and an
intramural hematoma may in turn exist independent of
a PAU). Extension may also cause intramedial dissection, or the plaque rupture may extend to the adventitia,
leading to a saccular pseudoaneurysm. Plaque rupture
extending through the adventitia can lead to hematoma.
Penetrating aortic ulceration is typically located in the
descending aorta, although involvement of the ascending aorta or arch has been described.
Clinical features of a PAU are similar to those of an
aortic dissection, but they represent a separate entity with
different prognosis and treatment. Surgical treatment is
usually reserved for cases in which persisting pain, hemodynamic instability, or signs of expansion are identified.
Asymptomatic patients are treated medically and receive

imaging follow-up. It has been hypothesized that the


asymptomatic presentation represents a less acute process, perhaps due to less prominent medial involvement,
with less potential to incite intramural hematoma, dissection, or other sequelae of PAUs.
The frequency of PAUs is lower than classic dissection, making awareness of its imaging findings an important feature of appropriate management. Aortic CT
examination should begin with a noncontrast series
because a PAU is frequently associated with an intramural hematoma. The intramural hematoma is often focal
because propagation is limited by medial fibrosis caused
by atherosclerosis. Displaced intimal calcifications
are an additional imaging feature that may be more easily identified on noncontrast images and in general
are more readily identified on CT than MRI. This
should be followed by postcontrast images, in which
penetrating ulcers are identified as discrete rounded outpouchings that fill with contrast. Penetrating aortic
ulceration may be differentiated from mural thrombus
by its more eccentric location and may also be associated
with aortic wall thickening, enhancement, dissection,
pseudoaneurysm, or rupture. Care should be taken to

198

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

C
n Figure 16-7 A, A precontrast axial image obtained at the level of the descending thoracic aorta
demonstrates high-attenuation material in the left pleural space (asterisk) and mediastinum (arrow),
consistent with a hematoma. B, A postcontrast axial image in the same patient shows a contrast-filled
outpouching (arrow) arising in an area of atherosclerotic plaque. C, A three-dimensional reformatted image
shows the irregular contour at the site of a penetrating atherosclerotic ulcer rupture (arrows), which is
partially contained and is consistent with a pseudoaneurysm that has ruptured. Note also the aortoiliac
stent graft material from previous abdominal aortic aneurysm repair.

differentiate PAUs from atheromatous ulcers that are


confined to the intimal layer, particularly if the patient
is asymptomatic and there is no intramural hemorrhage.

Case 8

Both CT and MRI provide reliable noninvasive diagnosis and follow-up of PAUs to guide management toward
either a conservative or interventional approach.

Coarctation of the Aorta

A 31-year-old man with hypertension and delayed pulses noted in the femoral
arteries was referred for cardiovascular CT (Fig. 16-8).

Chapter 16

C
n Figure 16-8 A, Axial image at the level of the pulmonary artery shows severe narrowing of the
descending thoracic aorta (white arrow). The internal mammary arteries are very large (arrowheads) as are the
intercostal collateral arteries (gray arrows), seen in the posterior mediastinum. B, A parasagittal maximum
intensity projection image demonstrates the severe narrowing in the aorta at the coarctation site
(white arrows) and the prominent intercostal (gray arrows) and internal mammary (arrowheads) arteries
serving as collaterals. C, Coronal maximum intensity projection image shows the markedly enlarged
internal mammary arteries (arrowheads) paralleling the sternum.

Aortic Disease

199

200

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

COMMENTS
Coarctation can be observed anywhere along the course
of the aorta. The most common location is just distal to
the origin of the left subclavian artery, close to the ligamentum arteriosum insertion. This condition is attributed to an abnormal plication of the aortic media,
producing a fibrous ridge that narrows the aortic lumen.
The region of obstruction may be focal, as in aortic coarctation; diffuse, as in cases of hypoplastic aortic isthmus; or
complete, resulting in aortic arch interruption. The aortic
wall may be abnormal beyond the actual site of coarctation. For instance, abnormal intima and disrupted elastic
tissue may be present distal to the coarctation, which
predisposes this area to infective endarteritis, as well as
dissection and aneurysm. Cystic medial degeneration frequently occurs in the aorta adjacent to the coarctation
site, posing an increased risk of aneurysm formation or
dissection.
Clinical manifestations are dependent on the site and
severity of luminal narrowing as well as associated cardiac and extracardiac anomalies, the most common
being bicuspid aortic valve. Aortic coarctation may be
brought to clinical attention by an associated heart murmur, diminution or delayed pulsation of femoral arteries
on physical examination, and headache or claudication
brought on by exercise.
Multiple therapeutic approaches are available for the
patient with aortic coarctation, guided by the morphology
of the coarctation and the patients age and clinical condition. Both surgical angioplasty and percutaneous balloon
angioplasty have yielded good results in cases of mild to
moderate stenosis. Accurate delineation of coarctation
anatomy and physiology is important in both the pretherapeutic planning stage and the post-procedure follow-up.
Residual coarctation and aortic arch hypoplasia may be
seen postoperatively when coarctation is repaired with
end-to-end anastomosis. A heightened risk of aneurysm
formation at the repair site after aortoplasty, as well as
restenosis, pseudoaneurysm, and aortic dissection are all

Case 9

complications that have been observed after balloon


angioplasty. These complications may be asymptomatic;
therefore, routine follow-up with imaging is an important
facet of postcoarctation repair management. Echocardiography can provide information on Doppler velocity
gradients across the coarctation, assessing for the presence of restenosis. However, patient body habitus may
limit acoustic windows and render this approach suboptimal in some cases. Both CT and MRI provide threedimensional data sets that allow unlimited imaging planes
in the region of the coarctation repair. MRI offers some
benefits to the patient requiring long-term follow-up,
including lack of ionizing radiation and quantification of
gradient and collateral flow through velocity-encoded,
phase-contrast sequences. In cases of aortic coarctation
associated with bicuspid aortic valve, MRI also provides
the ability for hemodynamic assessment of the valve for
associated stenosis or regurgitation.
Aortic pseudocoarctation is an unusual anomaly that
occurs when the third to seventh embryonic dorsal segments fail to fuse in appropriate fashion to form the normal left aortic arch. This yields an elongated aortic
arch and proximal descending thoracic aorta, and fixture
at the ligamentum arteriosum creates an abnormal
kinked appearance. The morphology is similar to
coarctation, but no significant gradient develops across
the kinked area, and therefore the term pseudo-kinking
is a more appropriate morphologic descriptor. However,
with aging, turbulent flow can cause dilation of the
pseudocoarctation, and in some cases, this may lead to
dissection.
CT and MRI are able to identify pseudocoarctation
and differentiate this condition from true cases of coarctation. Although the morphology of the aortic tortuosity
resembles coarctation, no fibrous ridge is present. Imaging features that are helpful in identifying pseudocoarctation include an elongated and high aortic arch,
without the presence of collateral vessels or significant
stenosis, which are characteristic of true coarctation.

Infectious Aortitis

A 72-year-old man with back pain had blood cultures positive for Salmonella. A CT
scan was performed (Fig. 16-9).

Chapter 16

n Figure 16-9 Axial images at the level of the left renal artery on
day 1 of hospitalization (A) show an eccentric rind of soft tissue
involving the right aortic wall with adjacent fat stranding. On day 13
of hospitalization (B), there is a notable decrease in the soft tissue rind
along the aortic wall, and widening of aortic diameter (indicated by
double ended arrows in A and B), indicating a rapid interval change in
aortic caliber. Pathology revealed Salmonella aortitis.

Aortic Disease

201

Case 10

Takayasus Aortitis

A 19-year-old woman with hypertension was referred for cardiovascular CT


(Fig. 16-10).

CO MMENTS
Aortitis simply refers to inflammation of the aorta. Aortitis can be categorized as infectious and noninfectious.
This is an important distinction because immunosuppressive therapy, a primary treatment for vasculitis,
may worsen an infectious process.
The most common infectious agents that may affect the
aorta are Staphylococcus spp., Escherichia coli, and Salmonella
spp. Additional causes include Mycobacterium tuberculosis,
Neisseria gonorrheae, fungal infections such as aspergillosis
and mucormycosis, and viral agents such as hepatitis B
and C viruses and herpesvirus. Noninfectious disorders
that affect the aorta include Takayasus arteritis, giant cell

arteritis, polyarteritis nodosa, sarcoidosis, systemic lupus


erythematosus, and rheumatoid arthritis. Significant
ethnic differences have been shown in the epidemiology
of several noninfectious causes of aortitis, including
Takayasus arteritis, and this disease process is more common in Asian countries. This suggests a genetic transmission, although the cause of this disease is not yet
elucidated. Additional causes of aortitis include transplant
rejection, inflammatory bowel disease, and paraneoplastic
vasculitis.
Avoidance of catheter-based angiography is desirable in
cases of aortitis due to an increased risk of pseudoaneurysm

202

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

C
n Figure 16-10 Axial images at the level of the great vessels (A) and left ventricle (B) show marked
circumferential wall thickening of the brachiocephalic and both common arteries (starting from left on image
A, vessels inscribed by arrows), and the descending thoracic aorta (arrows on image B). C, Candy cane view of the
aorta shows extensive wall thickening involving the entirety of the descending thoracic aorta (indicated by the
arrows) in this patient. The pattern of vessel involvement is suggestive of Takayasus arteritis.

formation at the arterial puncture site. CT findings that


suggest an infectious cause of aortitis include a dilated aorta
that rapidly expands (a saccular pseudoaneurysm that is
caused by weakening of the aortic wall), periaortic inflammation (such as fat stranding noted on Case 9) or hematoma, and adjacent gas collection. Even in the absence of
aortic dilation, this represents a risk of rupture. Imaging
findings that may be noted in noninfectious aortitis, such

as Takayasus arteritis, include stenotic lesions, typically at


the ostia of the arch vessels, aneurysmal dilation of the
aorta and its major branches, and aortic regurgitation due
to aortic root dilation. CTcharacterizes the changes associated with Takayasus arteritis with a high degree of accuracy. One small series of 25 patients with symptoms of
Takayasus arteritis reported a 95% sensitivity and 100%
specificity. However, the lack of ionizing radiation

Chapter 16

associated with MRI and the superior characterization of


vessel wall abnormalities make it an attractive choice in
the serial imaging assessment of noninfectious aortitis.
Magnetic resonance angiography allows characterization
of the morphologic changes associated with this condition,
including mural thickening and vessel caliber change, with
gadolinium enhancement of the wall serving as an indicator
of active inflammation. MRI can then also be used for serial
follow-up to assess treatment response, as indicated by
decreased wall thickness of involved arteries.

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Chapter

17

Valvular Heart Disease


Hatem Alkadhi

KEY POINTS
l

Cardiac computed tomography (CT) can acquire high-quality information about the morphology of the aortic and mitral valve apparatus.

CT of the aortic and mitral valves can quantitatively assess the degree of valvular stenosis
and regurgitation through planimetric measurements of the valve opening or regurgitant
orifice areas.

CT provides important information about the heart and surrounding soft-tissue and thoracic cage osseous structures and thus is a valuable tool in the preoperative planning of
complex cardiac surgery or minimally invasive procedures of the cardiac valves.

Cardiac CT can provide accurate data on coronary artery status in patients before cardiac
valvular surgery.

In patients with infective endocarditis, CT provides excellent morphoanatomic information


about associated abnormalities and provides a noninvasive alternative to invasive
angiography.

204

Chapter 17

Case 1

Valvular Heart Disease

205

Normal Anatomy: Aortic and Mitral Valve

A 55-year-old woman presented with recurrent atypical chest pain. Cardiac risk
factors included hypertension and a positive family history. Cardiac CT was
performed to rule out coronary artery disease in this patient (Fig. 17-1).

C
n Figure 17-1 A, Oblique axial reformat through the aortic valve during mid diastole (at 65% of the R-R interval) shows the normal anatomy
of a tricuspid valve with complete coaptation of smooth-edged valve cusps. B, Oblique coronal reformat parallel to the left ventricular
outflow tract during mid diastole (at 65% of the R-R interval) shows the normal anatomy of the aortic valve and aortic root. C, Oblique
axial reformat through the aortic valve during early systole (at 15% of the R-R interval) shows a normal, unrestricted systolic excursion of
the valve. D, Oblique axial reformat in the long axis of the left ventricle shows the open mitral valve during mid diastole (at 65% of the R-R
interval) with a normal anatomy of the anterior and posterior leaflets, mitral annulus, and subvalvular apparatus.
Continued

206

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

E
n Figure 17-1contd E, Reformatting through the short axis of the mitral valve during mid diastole (at 65% of the R-R interval) shows the
normal opening of the mitral valve leaflets. F, Oblique axial reformat through the long axis of the left ventricle shows the closed mitral
valve during early systole (at 15% of the R-R interval) with a normal coaptation of the anterior and posterior leaflets.

COMMENTS
Cardiac CTusually is performed for the noninvasive evaluation of the coronary arteries. Being a cross-sectional
imaging modality providing an isotropic voxel resolution,
CT simultaneously provides temporal and anatomic
information about the cardiac chambers and valves. Retrospective synchronization of the electrocardiogram
(electrocardiographic gating) allows the reconstruction

Case 2

of data sets at various systolic or diastolic phases of the


cardiac cycle. Thus, images can be reconstructed that
show the opened and closed cardiac valves in diastole
and systole. In general, images during diastole are characterized by fewer motion artifacts than those in systole, a
fact that is true not only for the coronary arteries but also
for the cardiac valves.

Anatomy: Bicuspid Aortic Valve Without Raphe

A 44-year-old woman presented with two episodes of atypical chest pain. Cardiac risk
factors included untreated hyperlipidemia. Multidetector row CTcoronary angiography
was performed to exclude the presence of coronary artery disease (Fig. 17-2).

n Figure 17-2 A, Oblique axial reformat during mid diastole (at 70% of the R-R interval) shows a closed bicuspid aortic valve with no raphe.
The two aortic cusps demonstrate normal coaptation with no regurgitant orifice. B, Oblique axial reformat during early systole (at 10% of
the R-R interval) shows the opening of the two aortic cusps. Echocardiography showed no aortic stenosis or regurgitation in this patient.

Chapter 17

CO MMENTS
A bicuspid aortic valve is composed of two cusps, usually
of unequal size. The larger cusp is referred to as the
conjoined cusp. Twenty-five percent of the bicuspid aortic valves have no raphe, or fibrous ridge, representing
the site of congenital fusion between the two components of the conjoined cups. Bicuspid aortic valves have

Case 3

Valvular Heart Disease

207

a prevalence of 1% to 2% in the general population,


with men being affected two to three times more frequently than women. With degeneration of aging valves,
sclerosis and calcification often occur, with changes similar to those in atherosclerotic coronary arteries. Most
bicuspid aortic valves will become progressively stenotic
or regurgitant.

Anatomy: Bicuspid Aortic Valve With Raphe

A 52-year-old woman with recurrent atypical chest pain with exercise was referred
for multidetector row CT coronary angiography for the evaluation of the coronary
arteries (Fig. 17-3). Cardiac risk factors included arterial hypertension and smoking.

n Figure 17-3 A, Oblique axial reformat through the aortic valve during mid diastole (at 65% of the R-R interval) shows thickened and
partially calcified aortic cups. B, Oblique axial reformat through the opened aortic valve during early systole (at 10% of the R-R interval)
shows fusion of the left and right coronary cusps by the partially calcified raphe (arrow). Computed tomography images reconstructed in
systole are important to establish the diagnosis of a bicuspid valve with a raphe and to distinguish the bicuspid from a tricuspid aortic valve.

CO MMENTS
A raphe is present in approximately 75% of bicuspid
aortic valves. The commissural fusion can be over a
short or long segment of the valve and can be solid or
fenestrated. In the majority of bicuspid valves with
raphe, the right and left coronary cusps are conjoined,

Case 4

with an unequal size in the majority of the valves.


Besides this, great variation in the morphology of bicuspid valves exists and is related to cusp size, calcification,
fibrosis, myxomatous degeneration, annular dilatation,
and commissural fusion.

Aortic Valve Calcium

A 62-year-old man with persistent exertional dyspnea and recurrent typical chest
pain underwent multidetector row CT coronary angiography for the evaluation of
the coronary arteries (Fig. 17-4). Cardiac risk factors included smoking, arterial
hypertension, and hyperlipidemia. CT demonstrated a significant stenosis of the mid
left anterior descending artery and mid right coronary artery. Echocardiography was
subsequently performed and revealed severe aortic stenosis.

208

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

B
4.5
R = 0.79, P < .0001

4.0
Aortic valve area, cm2

3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
0

1000 2000 3000 4000 5000 6000 7000 8000


EBCT Score

Peak aortic valve velocity, m/sec

R = 0.86, P < .0001

6
5
4

n Figure 17-4 A, Oblique axial reformat of the contrast-enhanced


scan through the level of the aortic valve shows extensive thickening
and calcifications of all three cusps. B, Oblique axial reformat of
the nonenhanced calcium scoring scan at the same level allows
accurate quantification of aortic valve calcification, similar to the
methodology used in evaluating the extent of coronary artery
calcification. C, The amount of aortic valve calcification has been
shown to be closely associated with the degree of aortic stenosis, with
a curvilinear relationship between the amount of calcification and
the degree of stenosis. The relationships between the aortic valve
calcification score (x axis) measured by electron beam computed
tomography (EBCT) and Doppler echocardiographic measurement
(y axis) of the aortic valve area (top) and peak aortic valve velocity
(bottom) are shown. (C, From Messika-Zeitoun D, Aubry MC,
Detaint D, et al: Evaluation and clinical implications of aortic valve
calcification measured by electron-beam computed tomography.
Circulation 110:356362, 2004, with permission.)

3
2
1
0
0

1000 2000 3000 4000 5000 6000 7000 8000

EBCT Score

COMMENTS
Degenerative aortic valve disease is due to thickening of
the valve apparatus with deposition of calcium. This is
associated with stiffness and restricted movement of
the cusps. Aortic valve calcification is not passive

scarring but is integral to aortic stenosis formation,


appearing early and accumulating through active and
highly regulated mechanisms. A significant correlation
has been shown between the amount of calcification in
the aortic valve, atherosclerotic risk factors, and the

Chapter 17

severity of coronary artery calcifications. In addition,


severe aortic valve calcification has been shown to be a
strong and independent predictor of adverse clinical outcomes and is associated with an increased rate of death.
The correlation between the amount of aortic valve

Case 5

Valvular Heart Disease

209

calcification and aortic stenosis severity (as determined


by echocardiography) is curvilinear, which suggests that
these two measures are complementary in assessing the
severity of the disease and predicting the outcome of
patients with calcified aortic stenosis.

Aortic Stenosis

A 55-year-old man with recurrent atypical chest pain and inconclusive exercise
myocardial perfusion scintigraphy underwent multidetector row CT coronary
angiography (Fig. 17-5). The physical examination revealed a systolic heart murmur.
Cardiac risk factors included arterial hypertension, hyperlipidemia, and smoking.
CT showed a significant stenosis of the mid left anterior descending artery and the
distal segment of the left circumflex coronary artery.

n Figure 17-5 A, Oblique axial reformat through the aortic valve during early systole (at 15% of the R-R
interval) shows restriction of the opening of the three cusps representing the morphologic correlate of
aortic stenosis. B, Planimetric measurements of the aortic valve area revealed an opening area of 0.6 cm2,
indicating severe aortic stenosis. Severe aortic stenosis was subsequently confirmed with echocardiography.

CO MMENTS
Aortic stenosis represents one the most common forms
of valvular heart disease in the elderly population.
The clinical mainstay in the diagnosis and grading of
aortic stenosis is two-dimensional and Doppler echocardiography. In some patients, however, echocardiography
may not be feasible and image quality can be hampered
by a suboptimal acoustic window or by severe valvular
calcifications causing acoustic shadowing. Magnetic resonance imaging may also be technically unfeasible or
inconclusive. Cardiac CT reconstructions in systole

show the opening of the aortic valve, which can be planimetrically measured for aortic valve area. CT represents a purely anatomic imaging modality providing
no information on hemodynamics; nevertheless, planimetric measurements with CT have shown a good
correlation with the grading of aortic stenosis on transthoracic or transesophageal echocardiography. Thus,
CT may be an alternative modality for grading aortic
stenosis in patients with technically limited images on
echocardiography or magnetic resonance imaging or if
these first-line modalities are not feasible.

210

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 6

Aortic Regurgitation

A 67-year-old woman with recurrent atypical chest pain, fatigue, and dyspnea under
ordinary physical activity was referred to multidetector row CT coronary
angiography for the evaluation of the coronary arteries (Fig. 17-6). The physical
examination revealed a diastolic heart murmur. Cardiac risk factors included a
positive family history. CT showed mild coronary calcifications but no significant
stenosis.

B
1.0

ROA: 75 mm2

Sensitivity

0.75

ROA: 25 mm2
0.5

0.25
mild/moderate vs. severe
mild vs. moderate/severe
0.0
0.0

0.25

0.5

0.75

1.0

1 Specificity

n Figure 17-6 A, Oblique axial reformat through the level of the aortic valve during mid diastole
(at 65% of the R-R interval) shows incomplete coaptation of the trileaflet aortic valve, creating a regurgitant
orifice. B, Planimetric measurements of the regurgitant orifice area revealed a value of 1.2 cm2,
indicating severe aortic regurgitation. This was subsequently confirmed with echocardiography. C, Receiver
operating characteristic curves showing the accuracy of planimetric regurgitant orifice area (ROA)
measurements with computed tomography in relation to the various grades of aortic regurgitation at
echocardiography. A regurgitant orifice area of 75 mm2 was an accurate correlate of severe aortic
regurgitation. (C, From Alkadhi H, Desbiolles L, Husmann L, et al: Aortic regurgitation: Assessment with
64-section CT. Radiology 245:111121, 2007, with permission.)

Chapter 17

Valvular Heart Disease

211

CO MMENTS
Aortic regurgitation is characterized by diastolic reflux
of blood from the ascending aorta into the left ventricle
and is caused by malcoaptation of the aortic cusps creating a regurgitant orifice. Common causes of aortic
regurgitation include aortic root and annular dilation,
bicuspid valve, infective endocarditis, or rheumatic disease. Depending on the cause, the valve cusps may be
thickened or shortened and may show commissural
lesions or calcifications. The regurgitant orifice area
represents an important surrogate marker to quantify

Case 7

the degree of aortic regurgitation with echocardiography. With CT, it is possible to planimetrically measure
the size of the anatomic regurgitant orifice area in mid
diastole. Interestingly, the values obtained from CT
show a significant correlation with the semiquantitative
classification of the severity of aortic regurgitation by
using clinically established echocardiographic techniques. With use of a cutoff regurgitant orifice area of
25 mm2 and 75 mm2, CT can accurately distinguish
mild, moderate, and severe aortic regurgitation.

Mitral Stenosis

A 49-year-old woman with recurrent atypical chest pain and dyspnea during mild
physical activity underwent multidetector row CT coronary angiography for
evaluation of possible coronary artery disease (Fig. 17-7). The physical examination
revealed a diastolic heart murmur. The patients history was remarkable for
rheumatic fever 17 years ago. The patient had no cardiac risk factors. The coronary
arteries were normal on CT. Echocardiography revealed a moderate mitral stenosis
in this patient.

n Figure 17-7 A, Oblique axial reformat along the long axis of the left ventricle shows partially calcified and thickened anterior and
posterior mitral valve leaflets. In addition, the reconstruction during mid diastole (at 65% of the R-R interval) shows a restricted opening of
the mitral valve (arrow) representing mitral stenosis. Note the associated severe enlargement of the left atrium. B, Perpendicular reformat
through the mitral valve at the tips of the leaflets allows planimetric measurements of the mitral valve area on computed tomography.

CO MMENTS
Mitral stenosis is characterized by an obstruction of the
left ventricular inflow at the level of the mitral valve that
is caused by a morphologic abnormality of the mitral
valve apparatus. In the majority of cases, mitral stenosis
is caused by rheumatic involvement of the mitral apparatus, causing progressive thickening and calcification of
the leaflets and chordae. Planimetry providing an

anatomic measure of the mitral valve orifice with echocardiography is considered the reference method for
grading mitral stenosis severity. CT similarly allows
performing planimetric measurements of the mitral
valve orifice in diastolic reconstructions. These measurements obtained with CT have been shown to be
accurate and reproducible in patients with mitral stenosis, with results comparable to those obtained with
echocardiography.

212

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 8

Mitral Valve Prolapse and Regurgitation

A 46-year-old woman presented with palpitations and progressive exertional


dyspnea. She underwent multidetector row CT coronary angiography for the
evaluation of the coronary artery status (Fig. 17-8). No cardiac risk factors were
identified. The physical examination revealed a systolic heart murmur. Coronary
artery disease could be ruled out with CT. Echocardiography revealed prolapse of
the anterior and posterior mitral leaflets and severe regurgitation.

n Figure 17-8 A, Oblique axial reformat along the long axis of the left ventricle during mid diastole (at
70% of the R-R interval) shows thickening of the anterior and posterior mitral valve leaflet and severe
calcifications of the posterior mitral annulus. Note the enlarged left atrium. B, Oblique axial reformat
along the long axis of the left ventricle during early systole (at 10% of the R-R interval) shows billowing of
the thickened leaflets beyond the mitral annulus plane representing mitral valve prolapse. In addition, a
coaptation defect of the leaflets is found that indicates mitral regurgitation (arrow).

COMMENTS
Mitral valve prolapse is a valvular heart disease that is
characterized by the displacement of an abnormally
thickened mitral valve leaflet into the left atrium during
systole. The prevalence of mitral prolapse in the general
population is 3% to 4% and identified in autopsy studies
in 7%. The female-to-male ratio is approximately 3:1.
Although the significance of mitral valve prolapse remains
controversial, patients with mitral valve prolapse have a
higher risk of infective endocarditis, cerebrovascular

Case 9

ischemia, sudden death, and mitral regurgitation. Because


of the relatively large and fast movement of the mitral
valve leaflets, planimetric assessment of the regurgitant
orifice area with CT is difficult to undertake and is occasionally not feasible. However, in some patients with
mitral regurgitation, planimetric measurements of the
regurgitant orifice area can be performed and show a
moderate correlation with semiquantitative grading from
echocardiography.

PreValve Surgery

A 45-year-old man with recurrent palpitations was admitted for echocardiography.


Echocardiography revealed an aneurysm of the aortic root causing annuloaortic
dilation and severe aortic regurgitation. The patient had no cardiac risk factors.
Multidetector row CTcoronary angiography was performed for the evaluation of the
coronary arteries before Tirone David surgery (Fig. 17-9). CT showed no coronary
plaques or stenoses.

Chapter 17

C
n Figure 17-9 A, Oblique axial reformat through the aortic valve during mid diastole (at 70% of the R-R
interval) demonstrates a coaptation defect of the tricuspid valve creating a regurgitant orifice. B, Curved
reformats along the center line of the left anterior descending, left circumflex, and right coronary arteries
showed no plaques or stenoses (left, center, and right). C, Axial and sagittal multiplanar reformats and a
volume-rendered sagittal image demonstrate the aneurysm of the aortic root (left, center, and right). In
addition, the origin and proximal course of the right coronary artery are depicted (arrows), which is
displaced and twisted because of the altered anatomy of the aortic root. The artery runs only approximately
1 cm behind the sternum, which is of potential danger when the sternotomy procedure is performed.

Valvular Heart Disease

213

214

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

COMMENTS
In patients undergoing cardiac valvular surgery, CT coronary angiography provides high diagnostic accuracy for
the diagnosis or exclusion of coronary artery disease.
Thus, CT represents an excellent initial test before valve
surgery to decide whether invasive catheter angiography
should be performed. Beyond the coronary arteries, CT

Case 10

provides excellent anatomic information of the heart


and coronary arteries and the relationship to the surrounding soft-tissue structures and osseous thoracic
cage. This anatomic information can be important for
the preoperative planning of complex surgery and is
particularly valuable for planning minimally invasive
cardiac procedures.

Infective Endocarditis of the Native Valve

A 71-year-old man presented with progressive fatigue for the past 6 months and a fever 1
month ago. For 2 weeks, the patient also experienced night sweats and shivering.
Echocardiography revealed vegetations on the aortic and mitral valve suggesting
infective endocarditis. Antibiotic therapy was initiated, and aortic valve replacement was
planned after 6 weeks. Multidetector row CTcoronary angiography was performed
before surgery to exclude the presence of coronary artery disease (Fig. 17-10).

B
n Figure 17-10 A, Oblique axial reformat and coronal volume-rendered image through the aortic valve during diastole (at 60% of the R-R
interval) show a large vegetation (arrows) arising from the noncoronary cusp. B, Oblique axial reformat during the mitral valve during
diastole (at 60% of the R-R interval) shows an additional, ill-defined vegetation (arrow) arising from posterior mitral valve leaflet.
Continued

Chapter 17

Valvular Heart Disease

215

C
n Figure 17-10contd C, Curved reformats along the center line of the left anterior descending, left circumflex, and right coronary
arteries show no plaques or stenoses in this patient (left, center, and right).

CO MMENTS
CT is able to depict morphologic abnormalities commonly associated with infective endocarditis. These
include vegetations (defined as irregularly shaped, oscillating masses, adherent to and distinct from the endocardium), abscesses (defined as irregularly shaped and
inhomogeneous paravalvular masses within the annulus,
periannular region, myocardium, or pericardium), pseudoaneurysms (defined as contrast-filled lesions having a
communication with the cardiac chambers or aortic root),

Case 11

fistula (defined as a direct continuation between the


chambers of the left and right heart), or leaflet perforation
(defined as a discontinuation of a cusp or leaflet). Beyond
the assessment of these abnormalities surrounding the
infected valve, CT provides accurate information about
the status of the coronary arteries. The major advantage
of CT over invasive catheter angiography for the evaluation of coronary anatomy is its noninvasiveness, which
avoids the high embolization risk of valvular vegetations
during catheter manipulations.

Infective Endocarditis of the Prosthetic Valve

A 58-year-old man with a history of mechanical aortic valve replacement 3 years


previously presented with fever and dyspnea. Echocardiography revealed infective
endocarditis with paravalvular leakage and vegetations at the prosthesis ring.
Multidetector row CT coronary angiography was performed to rule out coronary
artery disease and to demonstrate the relationship of the paravalvular leakage to the
coronary ostia before surgery (Fig. 17-11).

216

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

n Figure 17-11 A, Oblique axial reformats during diastole (at 65% of the R-R interval) and early systole
(at 10% of the R-R interval) show the mechanical aortic valve prosthesis surrounded by the large
paravalvular leakage and small vegetations (arrows) attached to the prosthesis ring. B, Volume-rendered
image showing the close relationship of the paravalvular leakage (asterisk) to the origin of the right and left
coronary ostia (arrows). C, Curved reformats along the center line of the left anterior descending, left
circumflex, and right coronary arteries show no plaques or stenoses in this patient (left, center, and right).

COMMENTS
CT is also able to depict morphologic abnormalities
commonly associated with infective endocarditis in
patients with prosthetic valves. In contrast to echocardiography, CT does not produce acoustic shadowing
behind mechanical valves and thus might be able to
depict vegetations that cannot be visualized by

echocardiography. At the same time, CT provides accurate information about the coronary arteries and thus
represents an excellent tool for assessing the coronary
artery status in these patients. Similar to the patients
with infective endocarditis of the native valves, noninvasive CT angiography avoids the risk of embolization
during invasive catheter angiography.

Chapter 17

SUGGESTED READINGS
Alkadhi H, Desbiolles L, Husmann L, et al: Aortic regurgitation:
Assessment with 64-section CT, Radiology 245:111121, 2007.
Alkadhi H, Wildermuth S, Bettex DA, et al: Mitral regurgitation:
Quantification with 16-detector row CTInitial experience, Radiology 238:454463, 2006.
Alkadhi H, Wildermuth S, Plass A, et al: Aortic stenosis: Comparative
evaluation of 16-detector row CT and echocardiography, Radiology
240:4755, 2006.
Feuchtner GM, Muller S, Grander W, et al: Aortic valve calcification
as quantified with multislice computed tomography predicts shortterm clinical outcome in patients with asymptomatic aortic stenosis,
J Heart Valve Dis 15:494498, 2006.
Gilard M, Cornily JC, Pennec PY, et al: Accuracy of multislice computed tomography in the preoperative assessment of coronary disease in patients with aortic valve stenosis, J Am Coll Cardiol
47:20202024, 2006.
Koos R, Kuhl HP, Muhlenbruch G, et al: Prevalence and clinical
importance of aortic valve calcification detected incidentally on
CT scans: Comparison with echocardiography, Radiology
241:7682, 2006.

Valvular Heart Disease

217

Meijboom WB, Mollet NR, Van Mieghem CAG, et al: Pre-operative


computed tomography coronary angiography to detect significant
coronary artery disease in patients referred for cardiac valve surgery,
J Am Coll Cardiol 48:16581665, 2006.
Messika-Zeitoun D, Aubry MC, Detaint D, et al: Evaluation and clinical implications of aortic valve calcification measured by electronbeam computed tomography, Circulation 110:356362, 2004.
Messika-Zeitoun D, Serfaty JM, Laissy JP, et al: Assessment of the
mitral valve area in patients with mitral stenosis by multislice computed tomography, J Am Coll Cardiol 48:411413, 2006.
Rosenhek R, Binder T, Porenta G, et al: Predictors of outcome in
severe, asymptomatic aorti stenosis, N Engl J Med 343:611617,
2000.
Sabet HY, Edwards WD, Tazelaar HD, Daly RC: Congenitally bicuspid aortic valves: A surgical pathology study of 542 cases (1991
through 1996) and a literature review of 2,715 additional cases, Mayo
Clin Proc 74:1426, 1999.
Scheffel H, Leschka S, Plass A, et al: Accuracy of 64-slice computed
tomography for the preoperative detection of coronary artery disease
in patients with chronic aortic regurgitation, Am J Cardiol
100:701706, 2007.

Chapter

18

Prosthetic Heart Valves


Tracy Q. Callister

KEY POINTS
l

Cardiovascular computed tomography (CT) using spiral acquisition for the examination of
systolic and diastolic images can fully depict valve leaflet motion and provide details on
soft-tissue anatomy surrounding the prosthesis.

Display settings including a wide window width can enable visualization of the metallic valvular structures.

In the setting of suspected prosthetic endocarditis, contrast-enhanced structures outside


of the normal valve ring dimensions can be indicative of valve ring abscess.

The finding of small areas of hypoattenuation surrounding metallic valvular elements can
represent pannus, thrombus, or vegetation. Evaluation of cine images for mobility characteristics can distinguish beam-hardening artifacts from abnormal tissue structures surrounding the valve.

Cardiac CT provides a detailed evaluation of vascular anatomy including vascular anomalies before valvular surgery. This includes anomalous venous drainage in the setting of right
ventricular volume overload.

218

Chapter 18

Case 1

Prosthetic Heart Valves

219

Prosthetic Valve Malfunction

A 54-year-old man presented with recent onset of fatigue and orthostasis 11 years
after aortic valve replacement (Fig. 18-1).

B
n Figure 18-1 A, The top two images show a St. Jude bileaflet valve in the aortic position shown in
diastole (left) and systole (right). There is clearly inadequate systolic excursion of one of the discs (top).
For comparison, the bottom two images show a properly opening split disc valve. B, A different patient
with a normally functioning bileaflet valve in the mitral position. Note the nearly complete and parallel
opening in the right image. This is the expected appearance with a split disc valve.
Continued

CO MMENTS
Mechanical valves are recommended for younger
patients (younger than 6065 years of age) based on
their superior durability. However, when malfunction
occurs, it is primarily noted as insufficient motion,
opening of the valve apparatus. Bioprosthetic and homograft valve malfunction occurs through gradual scarring

with a restrictive process with pannus ingrowth and


eventual calcification. Cardiovascular CT using spiral
acquisition for the examination of systolic and diastolic
images can fully depict valve motion and provide details
on soft-tissue anatomy surrounding the prosthesis. Prosthetic valves imaged with cardiac CT are best displayed
with a wide window.

220

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

E
n Figure 18-1contd C, Although a bileaflet valve should open completely, the Medtronic Hall
tilting disc valve seen here will open to only 70 degrees, even with normal function. The left panel
shows the valve in diastole (closed position); systole (fully open position) is shown to the right. D, The
thickened material seen emerging from the aortic wall and extending along the valve leaflets is the pannus
ingrowth seen with early malfunction of a human aortic homograft. Note also the small areas of
calcification in the top right image. The extent of soft tissue ingrowth can be appreciated in the bottom
right image with the valve annulus in cross section. E, The diastolic appearance of a normal Hancock
porcine heterograft valve depicts delicate leaflets. No pannus is present. Thick slice maximum intensity
projection displayed with a wide window width shows the valve ring and struts in total.

Case 2

Prosthetic Valve Subacute Bacterial Endocarditis

This 69-year-old man presented with extreme fatigue after international air travel. In
the emergency department, he was found to be in complete heart block (heart rate 34
beats per minute) with small bilateral pleural effusions. He had been asymptomatic
for the 3 years since having his aortic valve replaced (Fig. 18-2).

C
D
n Figure 18-2 A, Cross-sectional and long-axis views of the aortic root reveal a human homograft valve with a valve ring abscess (white
arrowheads) identified as a contrast-enhanced structure outside of the normal valve ring dimensions. B, Image (left) shows an inadequately
opening St. Jude bileaflet valve with an attached vegetation. Image (right) is a Hancock porcine heterograft with a valve abscess (white arrow).
(Courtesy of Dr. James Min.) C, Another patient with a vegetation on a bileaflet valve. The aortic valve prosthesis is in the diastolic position. The
vegetation is viewed as hypoattenuating structure on the ventricular surface of the valve. Small areas of hypoattenuation surrounding the
metallic valvular elements may represent beam-hardening artifacts. Evaluation of cine valvular images can distinguish mobile valvular
vegetations from small beam-hardening artifacts. (Courtesy of Dr. James Min.) D, A possible cause of a false-positive finding in the subacute
bacterial endocarditis evaluation. The normal sewing pledgets (white arrow) are used to secure the valve and any reattached aorta. Perivalve sewing
pledgets (inset). Per U.S. Food and Drug Administration requirement, these pledgets are radiopaque and must not be confused with valve
abscesses.

221

222

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

COMMENTS
In the outpatient evaluation of possible early subacute
bacterial endocarditis, a careful inspection of thin sections through the valve in at least two planes is required
to find small valve ring abscesses. These abscesses are an
earlier presentation in subacute bacterial endocarditis.
Although the valvular vegetations are more dramatic,

Case 3

they occur later in the course of subacute bacterial endocarditis and are more commonly found in the critically
ill. After aortic valve replacement, the normal appearance of surgical pledgets in the aortic wall can give the
false-positive appearance of a possible abscess, but can
be differentiated by their circumferential nature in the
aortic root.

Tricuspid Valve Repair

A 44-year-old man presented with persistent symptoms 1 year after tricuspid valve
repair. After surgery, his edema had resolved; however, he continued to be limited by
exertional dyspnea (Fig. 18-3).

B
n Figure 18-3 A, Thick maximum intensity projection of an axial view at the base of heart shows the right atrium, right ventricle, and left
ventricle (left). Coronal views of the heart and pulmonary veins (middle and right). The tricuspid ring (black arrowheads) used to narrow the dilated
annulus is appropriately sized. Previously undetected anomalous return of the left superior pulmonary vein (arrowhead circled in white) to the
innominate vein is now recognized. B, A second patient with severe tricuspid regurgitation due to a dilated valve annulus (white arrow) preparing
for surgery is noted to also have a persistent left superior vena cava (starburst) and a markedly dilated coronary sinus.

Chapter 18

CO MMENTS
Tricuspid regurgitation with chronic lower extremity
edema is frequently treated with a valvuloplasty through
surgical implantation of a valve annulus ring. Cardiac
CT is uniquely useful for identifying the underlying
causes of tricuspid regurgitation, which should be fully
delineated before surgery. Both pulmonary arterial and
venous hypertension or anomalous venous return can
be revealed but require extension of the imaging field
to include the full chest to ensure adequate evaluation.

SUGGESTED READINGS
Prosthetic Valve Malfunction
Butany J, Fayet C, Ahluwalia MS, et al: Biological replacement heart
valves. Identification and evaluation, Cardiovasc Pathol 12:119139,
2003.
Goldman ME: Echocardiographic Doppler evaluation of prosthetic
valve function and dysfunction, Adv Cardiol 41:179184, 2004.
Mehlman DJ: A pictorial and radiographic guide for identification of
prosthetic heart valve devices, Prog Cardiovasc Dis 30:441464, 1988.

Prosthetic Heart Valves

223

Vongpatanasin W, Hillis LD, Lange RA: Prosthetic heart valves,


N Engl J Med 335:407416, 1996.

Prosthetic Valve Subacute Bacterial Endocarditis


Baddour LM, Wilson WR, Bayer AS: Infective endocarditis: Diagnosis, antimicrobial therapy, and management of complications, Circulation 111:e394e434, 2005.
Dajani AS, Taubert KA, Wilson W, et al: Prevention of bacterial endocarditis. Recommendations by the American Heart Association, Circulation 96:358366, 1997.

Tricuspid Valve Repair


Frater R: Tricuspid insufficiency, J Thorac Cardiovasc Surg
122:427429, 2001.
Gatti G, Maffei G, Lusa AM, Pugliese P: Tricuspid valve repair with
the Cosgrove-Edwards annuloplasty system: early clinical and echocardiographic results, Ann Thorac Surg 72:764767, 2001.
Mullen JC, Waskiewich K, Bhargava R, Bentley MJ: Bilateral partial
anomalous pulmonary venous return, Can J Cardiol 13:567569,
1997.
Tighe DA, Thomas NV, Hafer JG: Diagnosis of partial anomalous
pulmonary venous connection with intact interatrial septum by
echocardiography, Echocardiography 15:405408, 1998.

Chapter

19

Pericardial Disease
Thomas C. Gerber, Birgit Kantor, and Eric E. Williamson

KEY POINTS
l

The normal pericardial thickness is less than 2 mm. Identification of the pericardium is
easiest on the anterior surface of the heart where separation by epicardial fat delineates
the fibrous pericardium.

The maximum thickness of a normal pericardial effusion is less than 4 mm. Effusions with
attenuation higher than that of water may suggest malignancy, hemopericardium, purulent exudate, hypothyroidism, or chylopericardium.

Pericardial cysts are usually round or elliptical with thin, smooth walls without internal
septa located in the anterior right costophrenic angle. The fluid contained is usually nondependent and low attenuation.

Absence of pericardium is most commonly partial, involving the left side, and manifests
as a leftward shift of the heart and a prominent left atrial appendage and pulmonary
artery. It can be associated with other congenital cardiac malformations.

Pericardial constriction can present with thickened or normal thickness pericardium. In the
setting of suggestive clinical findings, the presence of even small amounts of calcification
strongly suggests constrictive pericarditis. Absence of pericardial calcification does not
exclude constrictive pericarditis.

224

Chapter 19

Case 1

Pericardial Disease

225

Normal Pericardium

A 49-year-old asymptomatic, overweight man with hypertension and diabetes


presented for coronary computed tomography (CT) angiography to evaluate for
suspected coronary artery disease. On CT images gated retrospectively at 65% of the
R-R interval, myocardial thickness at the upper limits of normal in the septal and
lateral walls was noted. No coronary calcification or noncalcified coronary artery
plaque was present. The pericardium was normal (Fig. 19-1).

RV

LV

LV
RV

LV

SVC

IVC

n Figure 19-1 A, Maximum intensity projection (3-mm thickness) in


the horizontal long axis of the left ventricle (LV) at a level halfway between
the cranial and caudal ends of the heart. Pericardium of normal thickness
(arrowheads) is noted in the typical location over the free wall of the right
ventricle (RV) between the subpericardial (asterisk) and mediastinal (double
asterisk) layers of fat. Inability to visualize the pericardium in the absence
of surrounding fat (e.g., over the lateral and posterior walls of the LV)
is normal and does not by itself imply absence of the pericardium
(see case 4). B, Maximum intensity projection (3-mm thickness) in the
short axis at the level of the mid portion of the LV. Normal thickness
pericardium (arrowheads) is seen extending from near the diaphragm over
the RV to above the level of the pulmonary valve. Physiologic pericardial
fluid is seen along the inferior border of the myocardium (asterisk). C, The
superior (S), transverse (T), and oblique (O) pericardial recesses, part of
normal pericardial anatomy, may also contain small physiologic amounts
of pericardial fluid and should not be mistaken for pathologic conditions
such as aortic dissection, lymphadenopathy, or esophageal or bronchial
abnormalities. A, aorta; IVC, inferior vena cava; P, pulmonary artery; SVC,
superior vena cava. (From Truong MT, Erasmus JJ, Gladish GW, et al:
Anatomy of pericardial recesses on multidetector CT: Implications for
oncologic imaging. AJR Am J Roentgenol 181:11091113, 2003, with
permission.)

226

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

COMMENTS
Normal thickness of the pericardium on gated cardiac
CT is less than 2 mm. A small amount (50 mL) of pericardial fluid can be present. Pericardial fluid is typically
low attenuation and nonenhancing. Normal pericardium

Case 2

may erroneously appear thickened if a small amount


pericardial fluid is present or, especially on transaxial
images, if it is visualized tangentially where it changes
orientations from vertical to horizontal (e.g., near the
diaphragmatic surface of the heart).

Pericardial Effusion

A 72-year-old man presented for evaluation of slowly progressive shortness of


breath. A chest x-ray showed cardiomegaly that was new compared with an x-ray
obtained 3 years earlier. An echocardiogram showed pericardial effusion inferior and
posterior to the heart. The extent of the posterior effusion was uncertain. The
patient was referred for cardiac CT to address the volume and distribution of the
pericardial effusion and the options for pericardiocentesis (Fig. 19-2).

LA

LV
RV
RA
LV

LA

LV
RV

n Figure 19-2 A, Transaxial computed tomography image near the


diaphragmatic surface of the heart, gated at 70% of the R-R interval,
obtained during intravenous injection of contrast material at a level
approximately halfway between the cranial and caudal ends of the
heart. Water-density (0 Hounsfield units) fluid (asterisk) is present
posterior to the left ventricle (LV), consistent with pericardial effusion
separating the fibrous external fibrous and serous inner layers of the
pericardium. LA, left atrium, RA, right atrium; RV, right ventricle.
B, Maximum intensity projection (3-mm thickness) in the vertical
long axis. The inferior portion of the pericardial effusion (asterisks)
measured 36 mm in maximum width. C, Maximum intensity
projection (3-mm thickness) in the short axis at the level of the mid
portion of the LV. The effusion (asterisks) extended from posterior to
the LV to anterior to the RV. The pericardial effusion in this case was
determined to be idiopathic. The patient was treated conservatively,
and the effusion resolved over 19 months.

Chapter 19

Pericardial Disease

227

CO MMENTS
Echocardiography remains the mainstay of detecting
and examining pericardial effusions. CT may be helpful
for the examination of pericardial effusion in locations
difficult to assess with echocardiography, e.g., loculated
pericardial effusions posterior to the heart.
Pericardial fluid of more than 50 mL in volume,
which typically corresponds to a pericardial width

Case 3

greater than 4 mm, is considered abnormal. Small pericardial effusions are usually in dependent position dorsal
to the left ventricle on supine CT scans; however, larger
pericardial effusions are often circumferential. Effusions
with attenuation higher than that of water may suggest
malignancy, hemopericardium, purulent exudate, hypothyroidism, or chylopericardium.

Pericardial Cyst

A chest x-ray obtained in a 27-year-old smoker for chronic cough showed a mass in
the cardiophrenic angle. Gated cardiac CT was performed to confirm the tentative
diagnosis of a pericardial cyst (Fig. 19-3).

COMMENTS

RV

LV

Pericardial cysts are the result of redundant pericardium


being isolated from the main pericardial space during
embryologic development. They are usually round or
elliptical with thin smooth walls without internal septa.
Pericardial cysts are most common in the anterior right
costophrenic angle and usually contain nondependent,
low-attenuation fluid. However, they may also occur in
other locations and contain proteinaceous or hemorrhagic fluid, in which case the distinction from a solid
pericardial mass may be difficult. In these cases, lack of
enhancement after contrast administration can help to
confirm the diagnosis. Management is typically conservative with CT follow-up because expansion of the cyst
can occur and displace normal structures.

n Figure 19-3 A transaxial computed tomography image near


the diaphragmatic surface of the heart, gated at 60% of the R-R
interval, acquired 5 minutes after administration of 80 mL of
intravenous contrast medium. An elliptical, sharply defined
structure (asterisk) is present in the costophrenic angle anterior to
the left (LV) and right (RV) ventricles. The attenuation value of the
fluid is water density and does not enhance with contrast. This
position and appearance are typical of a pericardial cyst.

Case 4

Congenital Absence of the Pericardium

A 52-year-old asymptomatic man with dyslipidemia was noted to have an unusual


axis of the QRS complex on electrocardiography performed at his physicians office
for insurance purposes. A subsequent single-photon emission CT myocardial
perfusion stress test was markedly abnormal. Coronary CT angiography was
performed for further evaluation but showed no coronary calcification or
noncalcified coronary artery plaque. Incidentally noted was congenital absence of the
pericardium (Fig. 19-4).

228

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

RV

n Figure 19-4 A, The survey images (with the


patient in the supine position) show a leftward
shift of the heart with a prominent left ventricular
appendage portion of the cardiomediastinal
silhouette and increased cardiothoracic ratio.
B, The contrast-enhanced computed tomography
angiogram of the heart, shown here at a
reconstruction interval of 65% of the R-R interval
with a full field of view and 5-mm slice thickness at a
level approximately halfway between the cranial and
caudal ends of the heart, shows the leftward and
posterior shift to the position of the left ventricle
(LV). RV, right ventricle. (Courtesy of William Guy
Weigold, MD.)

LV

COMMENTS
Absence of pericardium is rare. In the majority of cases
(90%), absence of the pericardium is partial and usually
left sided. Patients are usually asymptomatic and identified based on an abnormal chest x-ray. Absence of pericardium, whether surgical (after pericardiectomy) or
congenital, does not usually affect cardiac function
except in the rare case in which, if the absence of pericardium is only partial, herniation of the left atrial
appendage or the left ventricle occurs, resulting in cardiac strangulation. Absence of pericardium can be

Case 5

associated (30% of cases) with other congenital cardiac


malformations such as atrial septal defects, patent ductus
arteriosus, and tetralogy of Fallot.
The CT typically shows a sagging and leftwardshifted left ventricle, often with a prominent left atrial
appendage and pulmonary artery. It is important to
remember (see case 1) that normal pericardium often
cannot be identified over the lateral and posterior wall
of the left ventricle. This normal appearance should
not be confused with absence of the pericardium.

Constrictive Pericarditis

A 57-year-old man presented for evaluation of severe fatigue, increasing shortness of


breath, lower extremity edema, and abdominal discomfort. Physical examination
revealed a jugular pressure of 14 cm with rapid x and y descent and pulsatile
hepatomegaly. Pulsus paradoxus, Kussmauls sign, or pericardial knock were all absent.

Chapter 19

Pericardial Disease

229

The chest x-ray showed no cardiomegaly. Echocardiography demonstrated a left


ventricular ejection fraction of 51%, biatrial enlargement, and high E velocity of
the mitral inflow signal. Pericardial thickness appeared normal. The patient was
referred for cardiac CT to address the suspected diagnosis of constrictive pericarditis
(Fig. 19-5).

RV
LV
RA
LA

n Figure 19-5 A, A transaxial computed tomography image near


the diaphragmatic surface of the heart, gated at 70% of the R-R
interval, obtained during intravenous injection of contrast material
at a level approximately halfway between the cranial and caudal ends
of the heart. The most important diagnostic features of constrictive
pericarditis are pericardial thickening (>4 mm, arrowhead) and
pericardial calcification (smaller arrow) posterior to the left ventricle
(LV). This patient also demonstrated other important diagnostic
features including local compression (arrow) and banana-shaped
tubular deformation of the entire LV and enlargement of the right
(RA) and left (LA) atria. RV, right ventricle. B, This maximum intensity
projection (3-mm thickness) in the short axis at the level of the mid
portion of the LV obtained in a different patient shows extensive
calcification (arrowheads) and thickening of the inferior and superior
portions of the pericardium.

LV

RV

CO MMENTS
Pericardial constriction is a specific form of diastolic
dysfunction caused by restraint in ventricular filling by
an abnormal pericardium. Currently, the most common
causes are previous pericardiotomy or radiation therapy.
It is important to distinguish pericardial constriction
from restrictive cardiomyopathy because of their distinct
therapeutic approaches. Constrictive pericarditis is

treated surgically, whereas restrictive cardiomyopathy is


treated medically.
Gross pericardial calcification is not common
(<30%), and calcification may be absent altogether. If
suggestive clinical symptoms are present, absence of
pericardial thickening or calcification does not rule out
pericardial constriction (40% of surgically proven constrictive pericarditis occurs with normal pericardial
thickness), but the presence of even small amounts of

230

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

calcification strongly suggests constrictive pericarditis in


this setting. In the absence of suggestive clinical symptoms, pericardial thickening or calcification alone does
not imply constrictive pericarditis. Pericardial effusions
are uncommon in constrictive pericarditis.

Pericardial Cyst
Axel L: Assessment of pericardial disease by magnetic resonance and
computed tomography, J Magn Reson Imaging 19:816826, 2004.
Schvartzman PR, White RD: Imaging of cardiac and paracardiac
masses, J Thorac Imaging 15:265273, 2000.

Congenital Absence of the Pericardium

SUGGESTED READINGS
Normal Pericardium
Bull RK, Edwards PD, Dixon AK: CT dimensions of the normal pericardium, Br J Radiol 71:923925, 1998.
Glockner JF: Computed tomography of the myocardium, pericardium,
and cardiac chambers. In Gerber TC, Kantor B, Williamson EE,
editors: Computed Tomography of the Cardiovascular System, London,
2007, Informa Healthcare, pp 211227.

Pericardial Effusion
Olson MC, Posniak HV, McDonald V, et al: Computed tomography
and magnetic resonance imaging of the pericardium, Radiographics
9:633649, 1989.
Wang ZJ, Reddy GP, Gotway MB, et al: CT and MR imaging of pericardial disease, Radiographics 23:S167S180, 2003.

Breen JF: Imaging of the pericardium, J Thorac Imaging 16:4754,


2001.
Gassner I, Judmaier W, Fink C, et al: Diagnosis of congenital pericardial defects, including a pathognomic sign for dangerous apical ventricular herniation, on magnetic resonance imaging, Br Heart J
74:6066, 1995.

Pericardial Constriction
Oren RM, Grover-McKay M, Stanford W, Weiss RM: Accurate preoperative diagnosis of pericardial constriction using cine computed
tomography, J Am Coll Cardiol 22:832838, 1993.
Talreja DR, Edwards WD, Danielson GK, et al: Constrictive pericarditis in 26 patients with histologically normal pericardial thickness,
Circulation 108:18521857, 2003.

Chapter

20

Adult Congenital Heart Disease


Stephen C. Cook

KEY POINTS
l

The number of adolescents and adults with not only simple but increasingly complex congenital heart disease (CHD) continues to grow at an exponential rate. Therefore, these
patients require lifelong noninvasive imaging modalities to accurately assess intricate anatomy and detect long-term complications often associated with previous palliative and
complete surgical repairs.

Although cardiac magnetic resonance imaging (MRI) is often the primary imaging method
of choice for many adults with CHD, metallic implants often used during transcatheter
procedures create significant signal void artifacts that preclude an accurate examination.
In addition, the increasing need for pacemakers and/or implantable cardioverter defibrillators in this aging population indicates a growing need to identify alternative imaging modalities for these patients.

Multidetector computed tomography (MDCT) accompanied by its multiple postprocessing


capabilities (maximum intensity projection, multiplanar reconstruction, and volumerendering technique) provides an alternative noninvasive imaging modality that is well suited
to assess the intracardiac anatomy of the adolescent or young adult with complex CHD.

Due to the diversity of lesions among adults with CHD, each MDCT examination should
be optimized to provide accurate anatomic coverage and optimal timing of contrast to
view structures of interest while simultaneously minimizing overall radiation dose in this
otherwise young population.

The interpretation of the adult with CHD requires a comprehensive knowledge of previous
palliative and/or complete repairs as well as the potential complications associated with
each type of repair.

A segmental approach to interpretation of complex CHD, followed by a secondary survey


of associated malformations, provides an organized, initial assessment of the anatomy.

231

232

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

MDCT overcomes the limitations of cardiac MRI and provides an accurate assessment of
the adult CHD patient who has undergone an interventional procedure. Specifically,
MDCT provides information regarding stent fracture, in-stent stenosis, and anatomy of
surrounding vessels that may not be accurately visualized during a cardiac MRI
examination.

Left and right ventricular volumes, often with complex geometry, and ejection fraction have
been accurately quantified with MDCT in adults with CHD.

There is an increased incidence of coronary anomalies in adults with CHD, which are often
difficult to image with invasive angiography due to aortic root enlargement or variation in
the site and number of coronary artery ostia. MDCT provides excellent visualization of the
course of the anomalous coronary artery and its relationship to complex surrounding anatomic structures.

Case 1

Atrial Septal Defect

A 41-year-old woman with a medical history of migraine headaches underwent a


transthoracic echocardiography and was found to have right atrial and ventricular
volume overload secondary to a large left-to-right intracardiac shunt at the atrial
level. Cardiac computed tomography (CT) was performed to further delineate the
anatomy of the atrial septum and pulmonary veins before transcatheter closure
(Fig. 20-1).

RA
LA
RA
RPA
LA

n Figure 20-1 A, An oblique axial view demonstrates the anatomy of the right superior pulmonary vein (arrow) and the absence of additional
defects (i.e., sinus venosus type atrial septal defect) in the superior portion of the atrial septum. LA, left atrium; RA, right atrium, RPA, right
pulmonary artery. B, This oblique sagittal view provides an alternative assessment to measuring the atrial septum to assist in the
preinterventional evaluation of the defect. Asterisk indicates secundum-type atrial septal defect.
Continued

Chapter 20

Adult Congenital Heart Disease

233

COMMENTS

RA

AoV

LA

A limited transthoracic echocardiogram initially suggested an atrial-level shunt as the etiology for this
patients right heart enlargement. Traditionally, transesophageal echocardiography has often been considered
the imaging modality of choice to further evaluate the
atrial septum when surface images fail to provide adequate information. However, this may be considered
semi-invasive by most patients and may not completely
evaluate complex abnormalities in pulmonary venous
anatomy and associated defects. Recently, MDCT has
been shown to provide a noninvasive assessment of the
atrial septum, including measurements, pulmonary
venous anatomy, and anatomic assessment of the inferior
and retroaortic rims, in addition to right ventricular size
and systolic function. Therefore, MDCT should be
considered an alternative noninvasive imaging modality
in the preinterventional assessment of the patient undergoing transcatheter closure.

n Figure 20-1contd C, The absence of a retroaortic rim


(arrowhead) may challenge the interventional team, but this
knowledge before the patients arrival to the catheterization
laboratory is helpful in choosing the device size. AoV, aortic valve.

Case 2

Patent Foramen Ovale

A 53-year-old woman with a history of cerebrovascular accident underwent


transcatheter placement of a 25-mm cribriform Amplatzer Septal Occluder (AGA
Corp., Plymouth, MN). One month later, she developed atypical symptoms of chest
pain. Initially, a transthoracic echocardiogram was obtained to evaluate the device,
but the study was technically challenging due to body habitus. Therefore, a cardiac
CT was obtained to further evaluate device position (Fig. 20-2).

CO MMENTS
Cardiovascular symptoms require thorough investigation after transcatheter therapy. However, management
of the adult patient who has undergone transcatheter
closure of a patent foramen ovale or atrial septal defect
in whom cardiovascular symptoms later develop has
not been completely established. Most centers recommend immediate transthoracic echocardiographic evaluation. Unfortunately, in the adult population, body
habitus precludes accurate assessment of the device.

Further, the echogenic nature of the device often prevents an accurate assessment of the device to surrounding anatomic structures. MDCT provides a high
degree of spatial resolution and an accurate assessment
of the device and its relationships to surrounding anatomic structures. Although transthoracic echocardiography is considered the first-line modality to assess
symptomatic patients after transcatheter closure,
MDCT should be considered to provide complementary
anatomic information.

234

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

SVC
RA

LA

RA

LA

RV

RA

LA

C
n Figure 20-2 A, This oblique axial five-chamber view shows that the device is in a stable position with
accurate visualization of both left and right atrial disks. There is no gross evidence of erosion through
the aortic root. In addition, there is no evidence of pericardial effusion. LA, left atrium; RA, right atrium.
B, An oblique sagittal view demonstrates that there is no evidence of obstruction to the systemic venous flow
to the right atrium by the right atrial disk. SVC, superior vena cava. C, An oblique axial view accurately
demonstrates the left and right atrial disks in relation to the aorta without acoustic shadowing. There is no
evidence of a residual left-to-right shunt or erosion at the level of the aortic root. RV, right ventricle.

Case 3

Ventricular Septal Defect

A 58-year-old male with a history of idiopathic dilated cardiomyopathy,


nonsustained ventricular tachycardia (VT) status post implantable cardioverterdefibrillator presented after receiving multiple shocks for ventricular tachycardia.
MDCT was performed to further assess the coronary artery anatomy (Fig. 20-3).

Chapter 20

Adult Congenital Heart Disease

235

LA
LV

LV

LA

n Figure 20-3 Oblique axial (A) and volume-rendered (B) images demonstrate a small residual
perimembranous ventricular septal defect (arrows) with left-to-right shunt of contrast. Note the
implantable cardioverter-defibrillator lead. LA, left atrium; LV, left ventricle.

CO MMENTS
Ventricular septal defects (VSDs) often result from
abnormal growth or development of one or more components of the ventricular septum. The four components that compose the ventricular septum include the
inlet, outlet, and muscular and perimembranous septum.
Echocardiography and cardiovascular MRI delineate the
morphologic features as well as provide hemodynamic
data in the adult with a VSD. MDCT also provides

Case 4

accurate morphologic and functional data in patients


with previously undiagnosed defects as well as in those
who have undergone previous surgical repairs. Visualization of the ventricular septum requires an adequate
saline bolus to completely clear the right ventricle of
contrast and to evaluate the ventricular septum for a
residual defect. In this case, MDCT provided simultaneous evaluation of the coronary arteries and ventricular
septal anatomy.

Subaortic Membrane

A 50-year-old woman with a medical history significant for a VSD and coarctation of
the aorta underwent resection of the coarctation segment with subsequent
anastomosis of the left subclavian artery and descending arch of the aorta and
placement of a pulmonary artery band. Later, she underwent take-down of the
pulmonary artery band and closure of the VSD. After years of intermittent
follow-up, a routine cardiac MRI examination (performed to assess aortic anatomy)
identified a 4.6-cm aneurysm of the transverse arch and a discrete area of
recoarctation. A cardiac CT was performed to noninvasively assess her coronary
anatomy before surgical reconstruction of the arch (Fig. 20-4).

CO MMENTS
Although subaortic membranes may occur in isolation,
they are commonly encountered in patients with multiple left-sided obstructive lesions. Frequently associated
congenital anomalies include coarctation of the aorta,
VSD, Shone complex (supravalval mitral ring, parachute

mitral valve, and coarctation), and valvar aortic stenosis.


MDCT provides pertinent anatomic information
regarding the exact morphology of the left ventricular
outflow tract and aortic valve as well secondary hemodynamic effects (left ventricular hypertrophy, left atrial
enlargement).

236

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

RV
LA
AoV
LV

LA

LV

Ao

LV

C
n Figure 20-4 A, An oblique axial image demonstrates a small ridge of tissue (arrowhead) along the left
ventricular outflow tract consistent with a subaortic membrane. The ventricular septal defect patch is easily
identified by focal areas of calcification (arrows). LA, left atrium; LV, left ventricle; RV, right ventricle. B, This
volume-rendered three-dimensional reconstruction also demonstrates the subaortic membrane with fibrous
attachments to the anterior leaflet of the mitral valve demonstrating a focal area of calcification (arrowhead).
Note the focal thickening of the bicuspid aortic valve (AoV). C, This oblique coronal image best delineates
the anatomy of the left ventricular outflow tract and the subaortic membrane (arrowheads). Ao, aorta.

Case 5

Bicuspid Aortic Valve

A 17-year-old adolescent male with a history of bicuspid aortic valve, patent ductus
arteriosus, and coarctation of the aorta underwent transcatheter repair at 11 years of
age. Due to significant susceptibility artifact from the stainless steel coils placed in
the patent ductus arteriosus, cardiac MRI was nondiagnostic. Therefore, cardiac CT
was performed to accurately assess his anatomy (Fig. 20-5).

Chapter 20

Adult Congenital Heart Disease

237

RV

RA
n Figure 20-5 A, Oblique axial
images in diastole (A) and systole
(B) demonstrate the classic features
of the bicuspid aortic valve. Note
the absence of the trileaflet
appearance of the valve during
diastole and the fish-mouth
appearance of the valve during
systole suggestive of normal aortic
valve area and function. Also, there
is no evidence of calcification of the
valve. LA, left atrium; LV, left
ventricle; RV, right ventricle. B, An
oblique coronal section
demonstrates the normal
appearance of the ascending aorta
and proximal transverse arch
without evidence of aneurysm. AAo,
ascending aorta; LV, left ventricle.

LA

AAo

LV

CO MMENTS
This patient was appropriately referred for CT due to limitations encountered during a cardiac MRI examination.
Therefore, all aspects of this young patients congenital
anatomy should be examined. Using this technique, the
bicuspid valve should be inspected for the degree of

Case 6

calcification and estimation of valve area. More importantly, patients with a bicuspid aortic valve are at a greater
risk of aortic root dilation as a result of intrinsic abnormalities in the aortic media and therefore should undergo close
inspection of the entire thoracic aorta.

Coarctation of the Aorta: Surgical Therapy

A 30-year-old woman with a history of bicuspid aortic valve and coarctation of the
aorta underwent cardiac CT to evaluate symptoms of chest pain (Fig. 20-6).
Previously, she underwent palliative repair with a left subclavian arteryto
descending aorta anastomosis in an end-to-side fashion. Subsequently, as a result of
increasing arm-leg blood pressure gradients, she underwent placement of an extraanatomic tube graft from the ascending to descending aorta.

238

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

RScIA

LCCA

RCCA

A
RScIA

B
n Figure 20-6 A, Volume-rendered three-dimensional reconstructions demonstrate the anatomy of the
previous (left) palliative procedure (left subclaviandescending aorta anastomosis; arrow) as well as the
anatomy of the extra-anatomic tube graft (right). LCCA, left common carotid artery; RCCA, right common
carotid artery; RSclA, right subclavian artery. B, A volume-rendered three-dimensional reconstruction
demonstrates the anatomy of the native aorta with severe coarctation (arrowhead). In addition, note the
anomalous right subclavian artery arising from the narrowed segment of the descending aorta.

COMMENTS
Late complications in the adult with coarctation of the
aorta after surgical repair are well described and vary
with each type of repair (end-to-end anastomosis, subclavian flap, patch angioplasty, interposition graft).
Common late-onset complications include hypertension, recoarctation, aneurysm formation of the

ascending aorta or at the site of previous repair, and


early-onset coronary artery disease. Therefore, the
CT examination of this complex patient should include
not only inspection of the coronary arteries (normal in
this case) but also thorough evaluation of previous
surgical repairs for potential late complications.

Chapter 20

Case 7

Adult Congenital Heart Disease

239

Coarctation of the Aorta: Primary Transcatheter Therapy

This 17-year-old patient with coarctation of the aorta underwent transcatheter repair
for refractory hypertension despite aggressive medical therapy. Cardiovascular CT
was performed to delineate the anatomy of the arch and stented segments
(Fig. 20-7).

LScIA

TAo

AAo

LA

RV

LScIA
RV

Ao

n Figure 20-7 A, An oblique


coronal image demonstrates
the detachable coils in the
ductus arteriosus (arrow) that
created the susceptibility
artifact on the cardiac magnetic
resonance imaging study. The
anatomy of the ascending aorta
(AAo) and transverse aorta
(TAo) are well visualized on
this examination. LA, left
atrium; LSclA, left subclavian
artery; RV, right ventricle. B,
Oblique sagittal (left) and axial
(right) views demonstrate
patency of the entire length of
the stent (arrows) without gross
evidence of in-stent stenosis.
Although the proximal end of
the stent is in close proximity
to the left subclavian artery, it
does not compromise the
luminal diameter of this vessel.
Ao, aorta.

LA

RV

CO MMENTS
Transcatheter therapy has become an increasingly common application in adolescents and young adults with
CHD to address primary underlying conditions as well
as secondary long-term complications (aneurysm,
recoarctation). Late complications from these interventions include stent fracture, in-stent restenosis, dissection, and aneurysm formation. Therefore, assessment
of transcatheter interventions has become an integral
part of the long-term assessment of the young adult with

CHD. MDCT provides a unique assessment of the


lumen of the stent beyond that of cardiac MRI. This is
particularly true in patients who have undergone interventions that are composed primarily of stainless
steel devices because this often leads to susceptibility
artifacts during MRI precluding accurate assessment of
the anatomic areas of interest as well as surrounding
structures.

240

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 8

Coarctation of the Aorta: Secondary Transcatheter Interventions

A 33-year-old patient with a history of coarctation of the aorta underwent late surgical
repair for a complex aneurysm involving the previous site of repair. Urgent surgical
resection of the aneurysm was performed, and it was repaired with an 18-mm graft that
required reimplantation of the left subclavian artery. His postoperative course was
complicated by rebound hypertension. Noninvasive imaging studies identified stenoses
of the transverse arch and ostia of the left subclavian artery that were subsequently
managed with transcatheter therapy. Due to severe, persistent hypertension, a follow-up
CTexamination was performed to assess the complex anatomy of the arch (Fig. 20-8).

COMMENTS
The complex surgical and transcatheter repair described
deserves close follow-up with noninvasive imaging.
MDCT provides a unique method to rapidly and

accurately assess not only the stented segments but also


the remainder of the ascending and descending aorta
that should be critically assessed in this patient
population.

LCCA
LScIA

AAo

A
LScIA
MPA

AAo

B
n Figure 20-8 A, An oblique sagittal image demonstrates the anatomy of the stent in the transverse arch. Note the small waist along the
undersurface of the arch (arrowhead). This anatomy is consistent with the previous interventional note that reported a residual waist in the mid
portion of the stent despite utilization of high-pressure balloons during the interventional procedure. However, the stent is well expanded within
the lumen of the arch without a significant area of recoarctation or in-stent stenosis. AAo, ascending aorta; LCCA, left common carotid artery;
LSclA, left subclavian artery.
Continued

Chapter 20

Adult Congenital Heart Disease

241

LScIA

C
n Figure 20-8contd B, Additional oblique sagittal (left) and axial (right) images demonstrate the anatomy of the stent that was used to
address the ostial left subclavian artery stenosis. Of note, the proximal portion of this stent protrudes into the lumen of the proximal descending
aorta (arrow). However, based on the luminal assessment of the descending aorta compared with the open-cell design of the stent, one would not
suspect that this would result in limitation of flow to the descending aorta. Just distal to the left subclavian artery, there is a questionable area of
dilation of the descending aorta (arrowhead). MPA, main pulmonary artery. C, Volume-rendered three-dimensional imaging is another useful
postprocessing imaging tool to assess complex transcatheter procedures. Anterior (left) and posterior (right) three-dimensional views of the arch
demonstrate an acute angulation of the proximal descending aorta (arrow) that has been created, likely as a result of the placement of multiple
stents in the transverse arch and proximal left subclavian artery. However, this segment will require attentive follow-up in subsequent
noninvasive examinations.

Case 9

Tetralogy of Fallot and Pulmonary Atresia

A 25-year-old man with a medical history significant for tetralogy of Fallot and
pulmonary atresia underwent MDCT to completely evaluate his underlying
anatomy, and right ventricular size and systolic function. CT was performed due to a
history of retained pacing wires (Fig. 20-9).

RV-PA

AAo

LV
RA

LV

RV

RV

n Figure 20-9 A, An oblique coronal image helps to identify the features of repaired tetralogy of Fallot with pulmonary atresia including the
calcified appearance of the ventricular septal defect patch (arrow) and the suggestion that there once may have been aortic override of the
ventricular septum. AAo, ascending aorta; LV, left ventricle; RA, right atrium; RV, right ventricle; RV-PA, right ventricletopulmonary artery.
B, Complete surgical palliation included placement of a 21-mm right ventricletopulmonary artery conduit (arrows). This oblique sagittal
view demonstrates patency of the proximal and distal aspects of the conduit with only minimal calcification.
Continued

242

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

RCA

AAo

AoV

RV-PA

RPA
LAD
LA
LPA
DAo

E
n Figure 20-9contd C, A thorough assessment of the branch pulmonary arteries is essential considering that this patient had undergone
multiple palliative procedures including modified Blalock-Taussig shunts to both the left and right pulmonary arteries before complete repair.
This oblique axial image confirms the absence of branch pulmonary artery stenosis. DAo, descending aorta; LPA, left pulmonary artery; RPA, right
pulmonary artery. D, Coronary artery abnormalities are commonly present in patients with tetralogy of Fallot. This oblique axial image
demonstrates the right coronary artery (RCA) and the left anterior descending artery (LAD) arising from the right coronary cusp. The left anterior
descending artery traverses between the aortic valve (AoV) and the right ventricletopulmonary artery conduit. A dual, diminutive left
anterior descending artery is noted from the left coronary cusp. LA, left atrium. E, The sinuses of Valsalva often dilate in patients with congenital
heart disease, particularly tetralogy of Fallot. Preliminary studies suggest that there are intrinsic abnormalities in the aortic root that predispose
to subsequent aortic root dilation. Therefore, a complete computed tomography examination should include examination of the aortic root.

COMMENTS
Although there are multiple noninvasive imaging modalities available to assess the young adult with repaired
tetralogy of Fallot with pulmonary atresia, this case

illustrates the ability of MDCT to assess the complex


intracardiac anatomy in these patients. MDCT is particularly suitable in patients who may have contraindications to MRI and those who cannot tolerate MRI.
Therefore, it is of utmost importance to have a complete

Chapter 20

understanding of the previous palliative and/or complete


repairs to maximize the results of this type of examination. An assessment of left ventricular size and systolic
function and coronary artery anatomy may require a
timing bolus optimized for contrast arrival to the aorta.
This is particularly helpful because there is an increased
incidence of coronary artery abnormalities in this
patient population, and it provides an accurate assessment of the ventricular septum to determine the

Case 10

Adult Congenital Heart Disease

243

presence or absence of a residual VSD. Alternatively,


assessment of right ventricular size and systolic function
and branch pulmonary artery anatomy requires optimal
timing of contrast to the main pulmonary artery. Finally,
if all anatomic structures are to be assessed in one examination, an intermediate timing bolus of contrast (equal
amount in the systemic and pulmonary ventricles)
should be used to opacify both left and right
circulations.

Double-Outlet Right Ventricle

A 43-year-old woman with double-outlet right ventricle developed symptoms of


increasing fatigue. Initially, she underwent a palliative classic right Blalock-Taussig
shunt (anastomosis of the subclavian artery to the pulmonary artery) and later
underwent a Rastelli procedure (in which a patch is used to direct oxygenated blood
from the left ventricle to the aorta) while at the same time closing the VSD. The
pulmonary valve is surgically closed, and a valved-conduit are constructed from the
pulmonary bifurcation to the right ventricle to allow deoxygenated blood to travel to
the lungs. CT was performed to assess the anatomy of the right ventricleto
pulmonary artery conduit (Fig. 20-10).

CO MMENTS
MDCT continues to demonstrate the key anatomic features necessary to complete a successful examination in
this adult with complex CHD. This information would

not have been provided by routine transthoracic echocardiographic imaging. Acoustic windows in the adult
with CHD are often limited by chest wall abnormalities, obesity, and pulmonary parenchymal issues.
Although cardiac MRI easily overcomes these

AoV
PV
RV

LV

LA
LV
LA

DAo

n Figure 20-10 A, At first glance, this oblique axial representation of a horizontal long-axis view suggests that the patient has had a successful
palliation of her previous underlying condition and the only abnormality noted here is a right-sided descending aorta (DAo). LA, left atrium;
LV, left ventricle. B, This oblique coronal image unveils her complex anatomy and displays the intracardiac repair that consisted of patch
closure of the ventricular septal defect (asterisk), establishing continuity between the left ventricle and the aorta. AoV, aortic valve; PV, pulmonic
valve; RV, right ventricle.
Continued

244

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

LPA
AAo

RPA

LPA

RA
RPA
RV

DAo

n Figure 20-10contd C, This oblique coronal image demonstrates the entire length of the 18-mm right ventricletopulmonary artery
conduit including a valve (arrows). Although there is no evidence of discrete obstruction or calcification, the conduit appears diffusely small with
poststenotic dilation of the proximal pulmonary arteries (right > left). LPA, left pulmonary artery; RPA, right pulmonary artery. D, The size
discrepancy between the conduit and the branch pulmonary arteries is appreciated on this oblique axial view. Even though there is no evidence
of distal conduit obstruction (asterisk), the diffuse branch pulmonary artery dilation suggests changes secondary to a proximal site of
obstruction.

limitations, MDCT provides complementary anatomic


imaging providing important information regarding
patency of the right ventricletopulmonary artery
conduit (presence/absence of calcification), distal

Case 11

pulmonary artery architecture, anatomy of the left


ventricular outflow tract, both left and right ventricular size and systolic function, and coronary artery
anatomy.

d-Transposition of the Great Arteries

A 30-year-old man with a history of d-transposition of the great arteries statuspost


Mustard repair and nonsustained ventricular tachycardia after implantable
cardioverter-defibrillator therapy presented with increasing shortness of breath and
easy fatigability with daily activities. Cardiac CT was performed to assess his
underlying anatomy and biventricular systolic function (Fig. 20-11).

COMMENTS
MDCT can be manipulated to answer multiple questions in the patient with d-transposition of the great
arteries who has undergone a Mustard and/or Senning
repair. In the case described, an intermediate timing
bolus of contrast was performed (equal amount in the
systemic and pulmonary ventricles) to assess biventricular size and systolic function. In addition, this type of
contrast injection provides the reader the ability to

evaluate both the systemic and pulmonary venous baffles


(presence/absence of baffle obstruction). However, to
assess the right ventricular systolic function and coronary artery anatomy alone, a timing bolus should be
triggered from a region of interest placed in the aorta
that is often anterior/rightward compared with the posterior/leftward position of the pulmonary artery. With a
thorough saline bolus, small baffle leaks may be detected
as well.

Chapter 20

Adult Congenital Heart Disease

245

MPA
RV
SVC
LV

PVA
LV

IVC

A
LAD
Ao

RCA
PVA
RV

C
n Figure 20-11 A, An oblique coronal view demonstrates the anatomy of the systemic venous atrium. Previously, the superior limb of the
systemic venous atrium had been completely obstructed, and therefore the implantable cardioverter-defibrillator lead had been placed
inferiorly (arrows). Subsequently, a stent was deployed to address the superior vena cava (SVC) obstruction. The superior vena cava stent is
patent. The pulmonary morphologic left ventricle appears dilated and is in continuity with the main pulmonary artery (MPA). IVC, inferior vena
cava; LV, left ventricle. B, An oblique axial image demonstrates the anatomy of the pulmonary venous atrium (PVA). There is a focal area of
calcification in the waist of this atrium (arrow). The morphologic systemic right ventricle is hypertrophied compared with the thin, smoothwalled, yet dilated appearance of the morphologic pulmonary left ventricle. C, This oblique coronal image demonstrates ventriculoarterial
discordance in a patient with d-transposition of the great arteries who has undergone a Mustard repair. The aorta (Ao) is noted arising from the
systemic right ventricle. The right ventricle is heavily trabeculated and enlarged in this patient with severe right ventricular dysfunction.
Both the right and left coronary arteries are seen arising from the proximal aorta. The pulmonary venous atrium is widely patent as it approaches the
tricuspid valve. RV, right ventricle; LAD, left anterior descending artery; PVA, pulmonary venous atrium; RCA, right coronary artery.

Case 12

Congenitally Corrected Transposition of the Great Arteries

A 24-year-old woman with mesocardia, congenitally corrected transposition of the


great arteries was found to have nonsustained ventricular tachycardia on routine
Holter monitoring. Due to retained pacing leads, cardiac CT was performed to
assess her intracardiac anatomy, coronary artery anatomy, and ventricular function
(Fig. 20-12).

246

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

AAo
LV
RV

LA
RA

LA

RV

LCX

LAD

AoV
PV
RCA

LA

C
n Figure 20-12 A, An oblique axial image demonstrates mesocardia. The pulmonary veins (arrows) are noted draining to the left atrium (LA)
that communicates with the morphologic right ventricle (RV). This anatomic finding is also described as atrioventricular discordance. The
morphologic systemic right ventricle in this case is defined by its coarse trabeculations compared with the smooth-walled appearance of the left
ventricle (LV) and the tricuspid valve hinge points (arrowheads) that are closer to the apex in contrast to the mitral valve apparatus. RA, right
atrium. B, This oblique sagittal image demonstrates atrioventricular and ventriculoarterial discordance. Here, the systemic right ventricle
communicates directly with the aorta. The brachiocephalic vessels (arrows) suggest that the great vessel arising from the systemic ventricle is the
aorta. AAo, ascending aorta.
Continued

COMMENTS
MDCT is well suited to depict the morphologic features
necessary to determine atrioventricular and ventriculoarterial discordance. More importantly, an accurate
assessment of right ventricular size and systolic function
is obtained during this examination. Last, details

regarding complex coronary artery anatomy are easily


depicted with the noninvasive imaging technique.
Therefore, this modality should be considered in the
assessment of the patient with complex congenitally corrected transposition of the great arteries who may have
contraindications to cardiac MRI.

Chapter 20

Adult Congenital Heart Disease

247

LCX
RCA

D
n Figure 20-12contd C, The aortic valve (AoV) lies anterior and leftward compared with the posterior and rightward position of the
pulmonic valve (PV). The coronary arteries are frequently inverted with right and left coronary arteries arising from the left- and right-facing
sinuses as seen in this oblique axial image. However, coronary artery abnormalities have been well described in this patient population with the
single coronary artery encountered as the most common variant. LAD, left anterior descending artery; LCX, left circumflex artery; RCA, right
coronary artery. D, An oblique coronal image (left) demonstrates the left circumflex branch running along the right atrioventricular groove.
In contrast, the right coronary artery continues along its course in the left atrioventricular groove toward the crux of the heart.

Case 13

Single Ventricle

A 20-year-old man with double-outlet right ventricle after single-ventricle palliation


(atriopulmonary anastomosis) and atrial arrhythmias presented with increasing
shortness of breath and easy fatigability. Cardiac MRI demonstrated a segmental wall
motion abnormality with associated scarring on delayed myocardial imaging.
Cardiac CT was performed to further evaluate his coronary and congenital anatomy
(Fig. 20-13).

Ao

LPA
LV

RV

LA
LV

n Figure 20-13 A, An axial oblique image demonstrates mesocardia. There is a muscular ventricular septal defect (arrow). The Fontan (asterisk)
palliation appears dilated. Previously, noninvasive transthoracic imaging has been limited by the appearance of the chest wall (concavity of
the chest secondary to multiple surgical operations). LA, left atrium; LV, left ventricle; RV, right ventricle. B, An oblique sagittal image
demonstrates the anatomy of the single ventricle. The aorta (Ao) arises from the anterior morphologic right ventricle. Here, contrast is seen
swirling in the severely dilated atriopulmonary anastomosis (asterisk). The proximal left pulmonary artery (LPA) is also seen in this view.
Continued

248

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

TA

RPA
Ao

RPA

LA
IVC

LPA

SVC
RPA

LPA

IVC

Ao

LAD
LCX

RCA
RV

LV

F
n Figure 20-13contd For legend see next page.

Chapter 20

Adult Congenital Heart Disease

249

n Figure 20-13contd C, An oblique coronal view demonstrates the length of the right pulmonary artery (RPA). Arrows denote likely
pathway taken to reach the pulmonary arteries by systemic venous blood returning from the lower extremities. Massive atriomegaly induced
by this Fontan modification (asterisk) can lead to low level of kinetic energy. TA, transverse arch. D, Both branch pulmonary arteries are
visualized in this oblique axial view. There is no evidence of branch pulmonary artery stenosis. E, This oblique sagittal view demonstrates the
anatomy of the entire Fontan with concomitant atriomegaly. This figure clearly demonstrates the challenge of performing computed
tomography scans in the single-ventricle patient population. There is swirling of contrast in the dilated portion of the Fontan (arrows).
Fortunately, contrast has migrated to the left and right pulmonary arteries. IVC, inferior vena cava; SVC, superior vena cava. F, An oblique
coronal image (left) demonstrates the anatomy of the proximal and mid right coronary artery. An oblique coronal image (right) demonstrates the
anatomy of the proximal segments of the left anterior descending artery (LAD) and circumflex coronary artery (LCX).

CO MMENTS
Assessment of the single-ventricle patient with MDCT
remains a unique challenge. The sluggish flow of blood
throughout the systemic venous system (Fontan) often
leads to an unequal distribution of contrast. Therefore,
knowledge of previous surgical palliation procedures
and clinical questions to be answered by the examination
should be acquired before scanning the patient. Acquisition of this information will be important for positioning an appropriate timing bolus. Together, this will
ultimately lead to improved image quality in this complex patient population. In the case described, the
clinical question was to evaluate the coronary artery
anatomy. Therefore, the timing bolus was placed in the
aorta. Fortunately, the coronary arteries were well visualized. However, one can appreciate that as a result of the
low cardiac output state often accompanied by singleventricle physiology and energy loss as a result of
massive atriomegaly from the atriopulmonary anastomosis, there is sufficient contrast opacification to evaluate the branch pulmonary arteries. Alternatively, scans
performed later on recirculation may have provided
greater information regarding the Fontan pathway
(presence/absence of obstruction, thrombus).

SUGGESTED READINGS
Aboulhosn J, Child JS: The adult with a Fontan operation, Curr
Cardiol Rep 9:331335, 2007.
Bashore TM: Adult congenital heart disease: Right ventricular outflow
tract lesions, Circulation 115:19331947, 2007.
Boxt LM: Magnetic resonance and computed tomographic evaluation
of congenital heart disease, J Magn Reson Imaging 19:827847, 2004.
Cook SC, Dyke P, Raman SV: Management of adults with congenital
heart disease with cardiovascular computed tomography, J Cardiovasc
Comput Tomogr 2:1222, 2008.
Cook SC, Raman SV: Unique application of multislice computed
tomography in adults with congenital heart disease, Int J Cardiol
119:101106, 2007.

Gade CL, Bergman G, Naidu S, et al: Comprehensive evaluation of


atrial septal defects in individuals undergoing percutaneous repair
by 64-detector row computed tomography, Int J Cardiovasc Imaging
23:397404, 2007.
Hornung TS, Derrick GP, Deanfield JE, Redington AN: Transposition
complexes in the adult: A changing perspective, Cardiol Clin
20:405420, 2002.
Inglessis I, Landzberg MJ: Interventional catheterization in adult congenital heart disease, Circulation 115:16221633, 2007.
Ismat FA, Baldwin HS, Karl TR, Weinberg PM: Coronary anatomy in
congenitally corrected transposition of the great arteries, Int J
Cardiol 86:207216, 2002.
Kaemmerer H, Stern H, Fratz S, et al: Imaging in adults with congenital cardiac disease (ACCD), Thorac Cardiovasc Surg 48:328335,
2000.
Lee T, Tsai IC, Fu YC, et al: MDCT evaluation after closure of atrial
septal defect with an Amplatzer septal occluder, AJR Am J Roentgenol
188:W431W439, 2007.
Lembcke A, Koch C, Dohmen PM, et al: Electrocardiographic-gated
multislice computed tomography for visualization of cardiac morphology in congenitally corrected transposition of the great arteries,
J Comput Assist Tomogr 29:234237, 2005.
Marie Valente A, Rhodes JF: Current indications and contraindications
for transcatheter atrial septal defect and patent foramen ovale device
closure, Am Heart J 153:8184, 2007.
Nicol ED, Gatzoulis M, Padley SPG, Rubens M: Assessment of adult congenital heart disease with multi-detector computed tomography
beyond coronary lumenography, Clin Radiol 62:518527, 2007.
Pouleur AC, le Polain de JB, Pasquet A, et al: Aortic valve area assessment: Multidetector CT compared with cine MR imaging and transthoracic and transesophageal echocardiography, Radiology 244:
745754, 2007.
Raman SV, Cook SC, McCarthy B, Ferketich A: Usefulness of multidetector row computed tomography to quantify right ventricular
size and function in adults with either tetralogy of Fallot or transposition of the great arteries, Am J Cardiol 95:683686, 2005.
Sebastia C, Quiroga S, Boye R, et al: Aortic stenosis: Spectrum of diseases depicted at multisection CT, Radiographics 23:S79S91, 2003.
Sridharan S, Yates R, Taylor AM: Optimizing imaging after coarctation
stenting: the clinical utility of multidetector computer tomography,
Catheter Cardiovasc Interv 66:420423, 2005.
Toro-Salazar OH, Steinberger J, Thomas W, et al: Long-term followup of patients after coarctation of the aorta repair, Am J Cardiol
89:541547, 2002.
Wang XM, Wu LB, Sun C, et al: Clinical application of 64-slice spiral
CT in the diagnosis of the tetralogy of Fallot, Eur J Radiol
64:296301, 2007.

Chapter

21

Intracardiac Masses
Amgad N. Makaryus and Lawrence M. Boxt

KEY POINTS
l

Computed tomography (CT) produces high-resolution, rapid-sequence scanning, allowing


detection of intracardiac and intrapericardial masses.

CT imaging, with its increased temporal and spatial resolution within a three-dimensional
volume, can differentiate and visualize the extent of intracardiac masses to a superior
degree compared with echocardiography and chest radiography.

Common intracardiac masses that need to be differentiated are masses attached to intracardiac chambers and those attached to valvular structures.

Masses, such as metastatic secondary tumors, or primary tumors, such as myxomas, need
to be differentiated from intracardiac thrombi.

Valvular lesions such as vegetations and tumors (i.e., papillary fibroelastoma) need to
be differentiated from each other, but this diagnostic differentiation may be limited by
suboptimal temporal resolution with CT for fast-moving masses attached to valvular
leaflets.

250

Chapter 21

Case 1

Intracardiac Masses

251

Left Atrial Myxoma

A 48-year-old woman with a family history of coronary artery disease presented for
the assessment of atypical chest pain. The patient related a history of sharp chest
pain that was not associated with exertion and lasted for as long as 10 minutes. She
had undergone Holter monitor testing because she also reported palpitations
associated with the chest pain, but this was unrevealing. Due to the atypical nature of
the chest pain, the patient was referred for CT coronary angiography to assess for
coronary artery disease. The patients coronary arteries were found to be normal, but
a left atrial mass was incidentally detected (Fig. 21-1).

IAS

n Figure 21-1 A, Axial view of multidetector computed


tomography (CT) images (12.5-cm spatial coverage in 5 seconds at a
gantry rotation speed of 330 msec, tube voltage 120 kVp [peak tube
voltage measured in kilovolts], tube current of 600700 mA, and
collimation of 64  0.625 mm). The arrow points to the left atrial
myxoma seen as a filling defect in the left atrium. This is a typical
location for an atrial myxoma with attachment to the fossa ovalis.
B, Oblique CT images delineate the exact location of the
myxoma attached to the interatrial septum and within the left
atrium. This multiplanar capability highlights one of the most
important benefits of CT with respect to three-dimensional
localization of anatomic structures within and adjacent to the heart.
C, Three-dimensional surface-rendered image. The observer is
within the left atrium looking toward the interatrial septum (IAS).
The left atrium displays the structure of the myxoma (asterisk).

252

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

COMMENTS
Most cardiac masses detected using contrast-enhanced
CT appear as filling defects within the cardiac chambers.
Among primary cardiac tumors, myxomas are the most
common, accounting for 40% to 50% of primary cardiac tumors. Approximately 90% are solitary and pedunculated, and 75% to 85% are isolated to the left atrium.
A many as 25% of cases are found in the right atrium.
Most myxomas are sporadic; however, approximately
10% are familial and are transmitted in an autosomal
dominant mode. Multiple tumors occur in approximately 50% of familial cases and are more frequently
located in the ventricle (13% vs. 2% in sporadic cases).
Myxomas are polypoid, round, or oval. They are
gelatinous with a smooth or lobulated surface. The most
common site of attachment is at the border of the fossa
ovalis in the left atrium, as in case 1, although myxomas
can also originate in the posterior atrial wall, the anterior atrial wall, or the atrial appendage. The mobility

Case 2

of the tumor depends on the extent of attachment to


the interatrial septum and the length of the attachment
stalk.
In approximately 20% of cases, a myxoma may be
asymptomatic and discovered as an incidental finding.
Associated constitutional symptoms, possibly related
to overproduction of interleukin-6, occur in 50% of
patients and include fever, weight loss, arthralgias, and
Raynauds phenomenon. Symptomatic cases occur due to
obstructive physiology (i.e., mitral valve obstruction) or
embolic (i.e., stroke or acute limb ischemia) events.
Differentiation of an atrial myxoma from a thrombus
is empirical and primarily based on the location within
the atrium. A myxoma can be differentiated from an
intra-atrial thrombus by its typical attachment to the
interatrial septum near the limbus of the fossa ovalis. A
left atrial thrombus often resides in or near the orifice
of the left atrial appendage and appears as a filling defect
on contrast-enhanced examination.

Mitral Valve Mass

A 67-year-old woman with a history of hypertension presented for the assessment of


atypical chest pain. The patient was referred for CT coronary angiography to assess
for coronary artery disease. The patients coronary arteries were found to be normal,
but an incidental finding of a mitral valve mass was found on the posterior mitral
valve leaflet (Fig. 21-2).

n Figure 21-2 A, Axial view of multidetector computed tomography images (12.5-cm spatial coverage in 5
seconds at a gantry rotation speed of 330 msec, tube voltage 120 kVp [peak tube voltage measured in
kilovolts], tube current of 600700 mA, and collimation of 64  0.625 mm). The arrow points to the 1.2-cm
mass on the posterior leaflet of the mitral valve. B, Right anterior oblique reconstruction highlights the
importance of differentiating the abnormal mass on the posterior mitral leaflet (arrow) from the normal
papillary muscles (asterisks).
Continued

Chapter 21

Intracardiac Masses

253

COMMENTS

LV

C
n Figure 21-2contd C, Left anterior oblique reconstruction
notes the mass on the posterior leaflet of the mitral valve (arrow).
LV, left ventricle.

Case 3

In this patient, this posterior mitral valve leaflet mass


was surgically excised and diagnosed on pathologic
examination as a myxoma. Although the most common
site of attachment is at the border of the fossa ovalis in
the left atrium, myxomas are rarely located on the mitral
valve with fewer than 40 cases reported in the literature.
Among these cases, the diagnosis was commonly made
at the time of autopsy. A clinical diagnosis was made in
the remaining cases based on the following symptoms:
peripheral embolism, cardiac signs of mitral valve
obstruction, and constitutional manifestations. The clinical presentation of mitral valve myxoma differs slightly
from that of other cardiac myxomas in that it has a lower
incidence of constitutional manifestations. The gold
standard for noninvasive diagnosis and localization of
valvular cardiac myxomas is generally transesophageal
echocardiography because of its high temporal resolution for the rapidly moving leaflets. Transesophageal
echocardiography also allows early detection of small
valvular tumors and may help to characterize better their
location and echostructure, facilitating the choice of an
optimal surgical approach through preoperative study
of the integrity and mobility of the valve. Conservative
operative treatment by resection of the area of implantation of the myxoma followed by suture repair of the
valve and annuloplasty may be recommended as the
most appropriate treatment option for this rare
condition.

Left Atrial Appendage Thrombus

A 72-year-old woman with a history of coronary stent implantation to the left


anterior descending artery 2 years before presented for the assessment of recurrent
chest pain on exertion. The patient also had a history of atrial fibrillation with sick
sinus syndrome, necessitating pacemaker placement and warfarin therapy 3 years
earlier. The patient was referred for CT coronary angiography to assess for
progression of her coronary artery disease. The patients coronary arteries and the
left anterior descending artery stent were found to be patent, but an incidental
finding of a left atrial appendage filling defect representing a thrombus was made
(Fig. 21-3).

CO MMENTS
Although most intracardiac masses present as spaceoccupying filling defects on CT, administration of intravenous contrast material aids the diagnosis. However,
unless an intracavitary filling defect is identified, diagnosis of the mass is difficult to make. Masses that represent
tumors are differentiated from intracardiac thrombi by
their typical attachments or locations within the cardiac
chambers. Differentiation of thrombi from other intracardiac masses such as atrial myxoma is empirical and
based on location within the atrium. A left atrial thrombus often resides in or near the orifice of the left atrial

appendage and appears as a filling defect on contrastenhanced examination, as seen in case 3. A right atrial
thrombus may be difficult to evaluate on CT. If contrast
is injected from the upper extremity, then unopacified
blood from the abdomen and lower extremities may
produce the appearance of a mass (representing the unopacified flow surrounded by opacified blood arriving
from above) within the chamber. A ventricular thrombus
appears as a filling defect immediately subjacent to the
myocardial wall. An intraventricular thrombus is most
commonly associated with previous myocardial infarction and thus regions of wall thinning.

254

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

LA

n Figure 21-3 A, Four-chamber oblique reconstruction (12.5-cm


spatial coverage in 5 seconds at a gantry rotation speed of 330 msec,
tube voltage 120 kVp [peak tube voltage measured in kilovolts], tube
current of 600700 mA, and collimation of 64  0.625 mm) shows
the pacemaker wire (arrows) within the right heart and the enlarged
left atrium (LA) in this patient with a history of atrial fibrillation.
B, Axial view of multidetector computed tomography images. The
arrow points to the low-attenuation filling defect within the left atrial
appendage. This represents a thrombus within the left atrial
appendage in this patient at risk of cardiac thrombus due to her
history of atrial fibrillation. C, Right anterior oblique reconstruction
shows the filling defect within the left atrial appendage (arrow).
Again noted is the enlarged left atrium.

LA

An intra-atrial thrombus is most commonly associated with hypercoagulable states and states of stasis
within the left atrium such as in patients with atrial
fibrillation or mitral stenosis. Stasis within the left
atrial appendage, in particular given very superior and
anterior location, can give the false-positive appearance
of thrombus. Techniques can be used on CT acquisition
to differentiate a thrombus within the left atrial
appendage from a filling artifact caused by varying

Case 4

contrast hemodynamics. These techniques include


prone imaging as well as delayed CT acquisition and
repeat imaging several minutes after the first-pass bolus
to allow greater time for full left atrial opacification.
Early reports on the use of cardiac CT to evaluate for
a left atrial appendage thrombus support a high negative predictive value, but larger series are needed that
compare standard techniques such as transesophageal
echocardiography.

Left Ventricular Fibrosarcoma

A 56-year-old woman with a history of mitral regurgitation who underwent mitral


valve repair with the placement of a mitral annular ring was evaluated with cardiac
CT for the evaluation of new-onset chest heaviness and dyspnea on exertion. The
patient also noted increasing fatigue over the previous 4 months and an unintended
10-pound weight loss over the same time period. The patients coronary arteries
showed minimal calcification without significant luminal narrowing. A large left
ventricular mass was noted (Fig. 21-4). Further workup including surgical pathology
revealed that the mass represented a malignant fibrosarcoma.

Chapter 21

Intracardiac Masses

255

LV

LV

LV

C
n Figure 21-4 A, Axial computed tomography (CT) image shows the filling defect within the left
ventricle (LV) and attached to and infiltrating the lateral left ventricular wall (arrow). Also noted is the
mitral annular ring (arrowheads). B, Right anterior oblique CT reconstruction shows the filling defect
(arrow) within the left ventricle. Also noted is the mitral annular ring (arrowheads). C, Left anterior oblique
reconstruction showing the filling defect (arrow) within the left ventricle attached to the lateral wall.

CO MMENTS
Primary myocardial tumors, including rhabdomyoma
and rhabdomyosarcoma, may be entirely intramyocardial and not evident on unenhanced CT examination.
Administration of intravenous contrast material may
increase contrast between normal myocardium and a
mass. However, unless an intracavitary filling defect is
identified, a diagnosis of tumor is difficult to make. Cardiac lymphoma appears on CTexamination as an infiltrating, intermediate-signal intensity mass. It usually involves
the pericardial space and extends along the base of the
heart between the great arteries and veins. Typically,
it separates and distorts these structures, but does not
cause obstruction. Extension through the myocardium

into the right-sided cardiac chambers is often demonstrated on contrast-enhanced scans.


A cardiac fibrosarcoma is a malignant tumor with a
cellular morphology of fibroblasts. It is a rare cardiac
tumor that represents approximately 5% of cardiac sarcomas in surgical series. On gross examination, fibrosarcomas have been described as soft, lobulated, gelatinous
masses. On CT, a low-attenuation tumor may obliterate
entire chambers, and some reports have described
necrotic areas in gross pathologic specimens, whereas
others have described a similar appearance on CT. A
fibrosarcoma may cause infiltration of the pericardium
by direct invasion or by the deposition of tumor nodules
in the inner pericardium.

256

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 5

Right Ventricular Liposarcoma

A 59-year-old woman with a history of a retroperitoneal liposarcoma was referred for


the evaluation of sudden shortness of breath. The patient underwent CT pulmonary
angiography for the evaluation of a pulmonary embolism. A large right ventricular
mass was noted (Fig. 21-5). Further workup including surgical pathology revealed
that the mass represented a liposarcoma metastatic to the right ventricle.

D
n Figure 21-5 A, Axial computed tomography (CT) image (500-msec gantry rotation, 4  2.5-mm collimation, 80 mA, and 120 kVp [peak
tube voltage measured in kilovolts]) shows the low-attenuation right ventricular liposarcoma (arrow) essentially filling the entire cavity of the
right ventricle. The lower Hounsfield intensity of the mass compared with the myocardial wall indicates the lipomatous nature of the mass
similar to subcutaneous fat (asterisk). B, Axial CT slice cephalad to Figure 21-5A shows extension of the mass into the right ventricular outflow
tract and main pulmonary artery (arrow). C, Coronal reconstruction again shows the right ventricular liposarcoma essentially filling the entire
cavity of the right ventricle into the right ventricle and main pulmonary artery (arrows). D, Three-dimensional volume-rendered reconstruction
of the heart shows the mass within the right ventricle (asterisk) displaying a different intensity than the surrounding myocardium. A Mediport
(arrow) is noted within the superior vena cava.

Chapter 21

CO MMENTS
This patient was noted to have multiple segmental and
subsegmental pulmonary emboli involving the bilateral
upper lobes and right lower lobe. Presumably, these
emboli are secondary to portions of the mass that embolized to the pulmonary arteries. Primary and metastatic
cardiac liposarcomas are extremely rare, but when they
occur, they usually originate in the right side of the
heart. These tumors may invade locally, infiltrate the
heart, or metastasize to the lungs. They are classified
histologically as well differentiated (lipoma-like), myxoid, round cell, or pleomorphic. Local extension is typical for well-differentiated and myxoid liposarcomas.
Affected patients are often asymptomatic until physiology consistent with constriction develops. Patients then
present with chest pain, dyspnea, dysrhythmia, and signs
of congestive heart failure. Conventional chest radiography may demonstrate an enlarged cardiac silhouette and
left lower lobe atelectasis. CT shows a hypoattenuated
mass. Magnetic resonance imaging may further delineate the extent and fatty nature of the lesion.

SUGGESTED READINGS
Left Atrial Myxoma
Grebenc ML, Rosado-de-Christenson ML, Green CE, et al: Cardiac
myxoma: Imaging features in 83 patients, Radiographics 22:673689,
2002.
Johnson TR, Clevert DA, Busch S, et al: Evaluation of left atrial myxoma by dual-source CT, Cardiovasc Intervent Radiol 30:10851086,
2007.
Tatli S, Lipton MJ: CT for intracardiac thrombi and tumors, Int J Cardiovasc Imaging 21:115131, 2005.
Vanleeuw P, Calozet Y, Eucher P, et al: Cardiac myxoma, Cardiovasc
Surg 1:654656, 1993.

Mitral Valve Mass


Chakfe N, Kretz JG, Valentin P, et al: Clinical presentation and treatment options for mitral valve myxoma, Ann Thorac Surg 64:872877,
1997.

Intracardiac Masses

257

Mart`n-Sua`rez S, Botta L, DellAmore A, et al: Mitral valve myxoma


involving both leaflets, Cardiovasc Pathol 16:189190, 2007.
Rocha AS, Ferreira ME, Dutra PR, et al: Myxoma of the mitral valve,
Arq Bras Cardiol 72:621626, 1999.

Left Atrial Appendage Thrombus


Gottlieb I, Pinheiro A, Brinker JA, et al: Diagnostic accuracy of arterial
phase 64-slice multidetector CT angiography for left atrial appendage thrombus in patients undergoing atrial fibrillation ablation,
J Cardiovasc Electrophysiol 19:247251, 2008.
Gottlieb I, Pinheiro A, Brinker JA, et al: Resolution of left atrial
appendage thrombus by 64-detector CT scan, J Cardiovasc Electrophysiol 19:103, 2008.
Kim YY, Klein AL, Halliburton SS, et al: Left atrial appendage filling
defects identified by multidetector computed tomography in
patients undergoing radiofrequency pulmonary vein antral isolation:
A comparison with transesophageal echocardiography, Am Heart J
154:11991205, 2007.
Tatli S, Lipton MJ: CT for intracardiac thrombi and tumors, Int J Cardiovasc Imaging 21:115131, 2005.

Left Ventricular Fibrosarcoma


Araoz PA, Eklund HE, Welch TJ, Breen JF: CT and MR imaging of
primary cardiac malignancies, Radiographics 19:14211434, 1999.
Shanmugam G: Primary cardiac sarcoma, Eur J Cardiothorac Surg
29:925932, 2006.
Tatli S, Lipton MJ: CT for intracardiac thrombi and tumors, Int J Cardiovasc Imaging 21:115131, 2005.
van Beek EJ, Stolpen AH, Khanna G, Thompson BH: CT and MRI of
pericardial and cardiac neoplastic disease, Cancer Imaging 7:1926,
2007.

Left Ventricular Liposarcoma


Chughtai A, Cronin P, Lucas DR, et al: Metastatic shoulder liposarcoma
to the right ventricle: CT findings, J Thorac Imaging 22:195198,
2007.
Kitamura A, Ozaki N, Mukohara N, et al: Primary cardiac liposarcoma
causing cardiac tamponade: Report of a case, Surg Today 37:974976,
2007.
Sugiyama K, Okubo T, Kamigaki Y, Kin H: Cardiac metastatic liposarcoma, Jpn J Thorac Cardiovasc Surg 48:663665, 2000.

Chapter

22

Noncardiac Findings Identified on


Cardiovascular CT
Jonathan D. Dodd and Ricardo C. Cury

KEY POINTS
l

The major organ systems that are assessable on cardiac computed tomography (CT) are
the lung parenchyma (including the pulmonary arteries), mediastinum, upper abdomen,
bones, pleura and chest wall.

Noncalcified pulmonary nodules are the most common noncardiac finding on cardiac CT
that require further workup. The Fleischner Society algorithm is a useful tool for the
management and for follow-up imaging for many small pulmonary nodules.

Other important thoracic pathologies assessable on cardiac CT include aortic dissection,


lymphadenopathy, pulmonary embolism, and hiatus hernia.

The most important incidental findings in the liver include benign cysts (most common),
hemangiomas, and malignancy, such as hepatocellular carcinoma or metastases.

Review of noncardiac structures provides the opportunity to make alternative diagnoses


that may account for the patients presentation or may detect important but clinically
silent problems such as early-stage lung cancer.

258

Chapter 22

Case 1

Noncardiac Findings Identified on Cardiovascular CT

259

The Routine Protocol

This 52-year-old man with atypical chest pain and positive family history underwent
cardiac CT for evaluation of the coronary arteries (Fig. 22-1).

n Figure 22-1 A, Axial computed tomography (CT) reformat


reconstructed as a large field of view to include the lung parenchyma.
The lobar fissures (straight arrows) are identified as white curvilinear
lines. The pulmonary ligaments (curved arrows) are normal structures
identified in the lower lobes, which provide structural support. Note
the airway walls should normally appear pencil thin (arrowhead).
B, Axial CT reformat reconstructed as a large field of view to include
the mediastinum. The superior vena cava (open arrow) can normally
be identified with dense contrast within it. The superior transverse
sinus (curved arrow) is commonly seen and should not be mistaken for
lymphadenopathy. The esophagus (arrowhead) lies behind the carina
and can be air filled, aiding identification. Note the azygous vein
(straight arrow). C, Axial reformat reconstructed as a large field of view
to include the bones. The important bones of the lower thorax are the
sternum (1), ribs (2), and spine (3). The ribs should be examined
carefully, because only a small proportion of a rib is seen on any one
axial image. The costal cartilages are often normally calcified
(arrowhead).

CO MMENTS
The major noncardiac structures that are assessable on
cardiac CT are the lungs (including the pulmonary
arteries), mediastinum, upper abdomen, bones, pleura
and chest wall. The lungs are the most important structure to be familiar with because they are the most common location of pathology, particularly pulmonary
nodules. The optimum window width to read the lungs

is 1500 Hounsfield units (HU) and the center is 700


HU. The optimum window width to read the mediastinum is 350 HU and the center is 50 HU. Slice thickness
for viewing these structures is usually between 3 and 5
mm. Knowledge of the normal appearance of these
organ systems is important to avoid misdiagnosis and
unnecessary further investigation.

260

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 2

Benign Pulmonary Nodules

In this section, we describe several cases. In the first case, a 51-year-old man with
atypical chest pain and positive family history for coronary artery disease underwent
cardiac CT (Fig. 22-2A). The patient never smoked. In the second case, a 72-yearold woman with chest pain was referred for cardiac CT for coronary artery
evaluation (Fig. 22-2B). In the third case, a 63-year-old man with atypical chest pain
and equivocal stress test underwent cardiac CT. He had no history of tobacco use
(Fig. 22-2C). In the fourth case, a 53-year-old man with chest pain and smoking
history underwent cardiac CT for noninvasive evaluation of the coronary arteries
(Fig. 22-2D). In the fifth case, a 42-year-old woman with chest pain underwent
cardiac CT to rule out coronary artery disease (Fig. 22-2E). She subsequently
developed hemoptysis.

B
n Figure 22-2 A, Axial computed tomography (CT) reformat demonstrates a tiny (3-mm long axis)
noncalcified nodule (curved arrow) in the inferior lingula. It has a smooth rather than a spiculated border and no
signs of infiltration. This patient was at low risk of malignancy (non-smoker), and no follow-up was needed for
this nodule. B, Axial CT reformat lung (left) and mediastinal (right) windows demonstrate a 7-mm nodule (arrows)
in the right lower lobe that is calcified throughout. This is the most reliable CT sign that a nodule is benign. This
diffuse type of calcification is characteristic of a granuloma, typically from tuberculosis or histoplasmosis.
Continued

Chapter 22

Noncardiac Findings Identified on Cardiovascular CT

E
n Figure 22-2contd C, Axial CT reformat demonstrates a 2.3-cm nodule in the left lower lobe with
a smooth border and a small focus of fat density (40 to 120 Hounsfield units) (curved arrow). Such
findings are virtually diagnostic of a benign hamartoma. D, Axial CT reformat shows a smooth,
curvilinear lesion in the left lower lobe. This filled homogenously with contrast. Note the feeding artery
(arrow, left) and draining vein (arrow, right). Such findings are pathognomonic of a pulmonary
arteriovenous malformation. E, Axial CT image demonstrates a cavitating nodule (12 mm) (arrow) in the
right lower lobe. The differential diagnosis for a cavitating nodule on CT includes infection (typically
tuberculosis, fungal infection, or septic emboli), inflammatory (Wegeners granulomatosis or rheumatoid
nodules), and neoplasia (squamous cell carcinoma typically cavitates). An antibody titer for cytoplasmicstaining antineutrophil cytoplasmic antibodies was positive, consistent with a diagnosis of Wegeners
granulomatosis.

261

262

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

COMMENTS
Incidental small noncalcified pulmonary nodules are by far
the most common noncardiac finding on cardiac CT. There
are several appearances of nodules that are pathognomonic
for a benign nodule, such as the presence of diffuse calcification or fat. Beware of the nodule with eccentric calcification
in one side of the nodule. This is not typical of a benign
granuloma and may occur in primary lung cancers that have
engulfed a granuloma. Hamartomas are the most common
benign tumor in the lung. They usually present between
the ages of 50 and 60 years. They are usually asymptomatic,
except for endobronchial lesions, when they cause obstructive airway symptoms. Aside from the presence of fat, a further characteristic CT feature is popcorn calcification,
although this is an uncommon appearance.
Pulmonary arteriovenous malformations may be
asymptomatic or may present with dyspnea and orthopnea.
They are usually associated with Osler-Weber-Rendu
syndrome with multiple arteriovenous malformations.

Complications include paradoxical embolism. Most can


be successfully treated with embolic therapy. As vascular
abnormalities, they should never be referred for percutaneous biopsy. Cavitating nodules represent a diagnostic
difficulty. A useful CT feature differentiating benign
from malignant causes is wall thickness. Cavity walls less
than 5 mm are usually benign, whereas walls greater
than 15 mm are almost always malignant. The clinical
history is important in differentiating the cause.
The Fleischner Society issued guidelines for the followup and management of pulmonary nodules incidentally
detected on CT (Table 22-1). In the example in Figure 221A, the patient was at low risk of lung cancer. Thus, for a
nodule less than 4 mm in the long axis, as Table 22-1 suggests, no further imaging was necessary. If the patient had
been a high-risk patient (smoker or strong family history
for lung cancer), then follow-up CT in 12 months would
have been advised; if unchanged at that stage, no further
imaging would have been necessary.

TABLE 22-1 Fleischner Society Guidelines for Follow-up and Management of Pulmonary Nodules Incidentally Detected on
Computed Tomography
NODULE SIZE
(MM)*

LOW-RISK PATIENT{
}

4

No follow-up needed

>46

Follow-up CT at 12 mo; if unchanged, no further follow-upk

>68

Initial follow-up CT at 612 mo, then at 1824 mo if no change

>8

Follow-up CT at approximately 3, 9, and 24 mo, dynamic


contrast-enhanced CT, PET, and/or biopsy

HIGH-RISK PATIENT{
Follow-up CT at 12 mo; if unchanged, no further
follow-up
Initial follow-up CT at 612 mo, then at 1824
mo if no changek
Initial follow-up CT at 36 mo, then at 912 and
24 mo if no change
Same as for low-risk patient

Recommendations for follow-up and management of nodules smaller than 8 mm detected incidentally on nonscreening computed tomography
Newly detected indeterminate nodule in persons 35 years of age or older.
*Average of length and width.
{
Minimal or no history of smoking and of other known risk factors.
{
History of smoking or of other known risk factors.
}
The risk of malignancy in this category (<1%) is substantially less than that in a baseline CT scan of an asymptomatic smoker.
k
Nonsolid (ground-glass) or partly solid nodules may require longer follow-up to exclude indolent adenocarcinoma.
CT, computed tomography; PET, positron-emission tomography.
From Macmahon H, Austin JH, Gamsu G, et al: Guidelines for management of small pulmonary nodules detected on CT scans: A statement from the Fleischner
Society. Radiology 237:395400, 2005.

Case 3

Malignant Pulmonary Nodules

In the first case, a 62-year-old man with chest pain and positive family history for
coronary artery disease underwent cardiac CT (Fig. 22-3A). He was a lifelong
smoker. In the second case, a 62-year-old man with chest pain with a history of
coronary artery bypass grafts underwent cardiac CT for graft assessment
(Fig. 22-3B). In the third case, a 54-year-old woman with dyspnea underwent cardiac
CT to assess her coronary arteries (Fig. 22-3C). In the fourth case, a 51-year-old man
with breathlessness underwent a triple rule-out CT to exclude a pulmonary embolus
and coronary artery disease (Fig. 22-3D). He was a lifelong smoker. In the last
case, a 51-year-old man with atypical chest pain and positive family history
for coronary artery disease underwent cardiac CT (Fig. 22-3E ). He had a history
of squamous cell carcinoma of the pharynx. He was a lifelong smoker.

Chapter 22

Noncardiac Findings Identified on Cardiovascular CT

263

n Figure 22-3 A, Axial computed tomography (CT) reformat shows a large mass (arrow) in the left upper lobe. The margins of the mass are
spiculated (termed a corona radiata), which is an important CT sign of malignancy. He underwent surgical lobectomy revealing primary
adenocarcinoma. B, Axial CT reformat shows a mixed solid/ground glass nodule (arrow) in the left upper lobe. CT lung cancer screening studies
have identified that mixed nodules with a solid/ground glass appearance appear to have a higher prevalence of malignancy than purely solid
nodules. Ground-glass density is defined as a hazy increased opacity of lung, with preservation of bronchial and vascular margins. C, It is
important not to disregard a pure ground-glass nodule (arrow). A small proportion of these turn out to be bronchoalveolar cell
carcinomas. D, Axial CT reformat demonstrates a spiculated nodule in the right upper lobe. The nodule contains bubble-like lucencies, and
such nodules have a strong association with adenocarcinoma. In particular, the bronchoalveolar cell subtype has this appearance (occasionally
pulmonary lymphoma can have a similar appearance). Biopsy showed this lesion to be adenocarcinoma with a bronchoalveolar component. E,
Multiple noncalcified nodules of varying sizes are noted throughout the lungs. The largest nodule in the left lower lobe measured 13 mm in the
long axis. Such findings are strongly suspicious for pulmonary metastases. Percutaneous CT-guided biopsy revealed squamous cell carcinoma.

264

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

COMMENTS
The likelihood of malignancy in the lungs strongly relates
to the size of the nodule. Almost all masses greater than
3 cm are malignant. Beware of nodule calcification.
Pulmonary carcinomas may also contain calcification,
but it is usually eccentric. If a pulmonary carcinoma is suspected, images should be carefully reviewed for invasion
of local structures, particularly the ribs and spine. Bronchoalveolar cell carcinomas are a particular type of adenocarcinoma that are usually slower growing tumors with a
lower risk of nodal metastases and an improved prognosis

Case 4

compared with other types of lung cancers. The bubblelike lucencies in these nodules are caused by small airways
remaining patent within the tumor. A spiculated nodule
border is always suspicious for a malignant nodule. This
is caused by either a desmoplastic reaction to the tumor
or local lymphatic infiltration by the tumor. Pulmonary
metastases are usually smooth walled rather than spiculated and are usually most numerous in the lung bases,
reflecting the increased blood flow in this zone of the
lung. They are usually multiple and of varying sizes.
Rarely, they can be so numerous as to be miliary.

Mediastinal Lymphadenopathy

A 62-year-old man presented with chest pain. Cardiac CTwas performed to exclude
coronary artery disease (Fig. 22-4A). In the next case, a 38-year-old man presented with
atypical chest pain (Fig. 22-4B). In the last case, a 48-year-old man with atypical chest
pain underwent cardiac CT to exclude coronary artery disease (Fig. 22-4C).

21mm
15mm

n Figure 22-4 A, Axial computed tomography (CT) reformat


shows an enlarged (15 mm) left hilar node (arrow). A bronchoscopy
biopsy showed small cell lung cancer. B, Axial CT reformat
demonstrates extensive lymphadenopathy in the mediastinum. Note
the large nodes in the subcarinal region (solid arrow) measuring 21
mm in the short axis and also in the pretracheal station (open arrow).
Note also the superior vena cava obstruction (curved arrow) caused
by extrinsic compression from the nodes. Mediastinoscopy
showed small cell carcinoma. C, Axial CT reformat demonstrates a
large hiatus hernia (arrow) in the posterior mediastinum. Note that
it is partially air filled and has a characteristically smooth outer
border. It can be followed caudally into the stomach. It can often
appear thick walled due to peristalsis.

Chapter 22

Noncardiac Findings Identified on Cardiovascular CT

265

CO MMENTS
Normal lymph nodes are smooth and ovoid in outline
and shape. The normal size of lymph nodes varies
depending on the location in the mediastinum. A widely
used approach is to consider all nodes greater than 10
mm in the shortest dimension as abnormal. They should

Case 5

not be mistaken for the normal pericardial recesses.


Malignant nodes will often have a low-density center
related to nodal necrosis. Calcified nodes are almost
always indicative of previous remote tuberculosis or
histoplasmosis exposure.

Lung Parenchyma

The first presenting patient was admitted with atrial fibrillation and underwent
cardiac CT to exclude significant coronary artery disease (Fig. 22-5A). In the next
case, a 69-year-old man with chest pain and known chronic lung disease
underwent cardiac CT to exclude significant coronary artery disease (Fig. 22-5B). In
the last case, a 72-year-old man presented with atypical chest pain. He was a lifelong
smoker (Fig. 22-5C).

n Figure 22-5 A, Axial computed tomography (CT) reformat (lung


windows) demonstrates extensive homogeneous opacities
(consolidation) through much of the lower lobes and some of the
upper lobes. Note the reassuring air bronchograms (arrowheads)
within the consolidation. Sputum culture was positive for
Streptococcus. B, Axial CT reformat demonstrates extensive increased
lines (reticulation) and multiple small cystic air spaces
(honeycombing) throughout the lower lobes. Such appearances are
classic for idiopathic pulmonary fibrosis. There is associated groundglass opacities and traction bronchiectasis (arrow) (indicating a
fibrotic process). C, Axial CT reformat shows extensive large cystic air
spaces depicted as black holes (emphysema) within the lung
parenchyma. Note the striking subpleural (within 1 cm of the pleura)
distribution (arrowheads) involving both lungs. This is characteristic
of paraseptal-type emphysema, but there are areas of mild
centrilobular emphysema also; these tend to occur within the central
parenchyma (curved arrow).

266

ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

COMMENTS
The most common differential diagnosis for diffuse
parenchymal lung disease on cardiac CT includes infection, but diffuse pulmonary hemorrhage and sometimes
pulmonary edema can also cause diffuse consolidation in
the appropriate clinical context. The most common causative organisms in adults include Mycoplasma pneumoniae,
Streptococcus pneumoniae, and Haemophilus influenzae.

Case 6

Idiopathic pulmonary fibrosis is the most common


fibrotic lung disease. Most patients are older than 50
years of age and typically report progressive dyspnea.
Note that pulmonary carcinoma develops in approximately 10% of these patients. Idiopathic pulmonary
fibrosis carries significant morbidity and mortality, the
median survival being 2 to 4 years (5-year survival rate
of 30%50%).

Liver Lesions

In the first case, a 56-year-old man presented with chest pain and a low pretest
probability of obstructive coronary artery disease (Fig. 22-6A). In the next case, a
65-year-old man with atypical chest pain underwent a cardiac CT
(Fig. 22-6B). In the last case, a 73-year-old woman with a history of colon cancer
presented with atypical chest pain (Fig. 22-6C).

B
n Figure 22-6 A, Axial computed tomography (CT) reformat of the liver demonstrates a sharply circumscribed, homogeneous low-density
lesion (arrow) in the left lobe. It measures less than 10 mm in longest dimensions. The majority of such lesions represent simple cysts
(there is another small hypodense lesion peripherally in the right hepatic lobe). B, Axial CT reformat of the liver shows an ill-defined enhancing
lesion (arrowheads) in the right lobe. Cardiac CT is an arterial phase CT with a rapid bolus infusion and will emphasize lesions that enhance
on the arterial phase. These include transient hepatic attenuation differences, hemangiomas, focal nodular hyperplasia adenomas, and hepatic
carcinoma. Note that the portal venous phase liver CT (right), in which the lesion is no longer identified, would be consistent with a transient
hepatic attenuation difference.
Continued

Chapter 22

Noncardiac Findings Identified on Cardiovascular CT

267

COMMENTS

C
n Figure 22-6contd C, Axial CT reformat demonstrates
multiple low-density, ill-defined lesions of varying sizes (arrowheads)
scattered throughout the liver. In the setting of a previous known
primary tumor, such lesions are strongly suspicious for metastases.
Note the poor definition of the lesion walls, which seem to blend
into the surrounding normal liver parenchyma, a common
appearance for metastases in the liver. Ultrasound-guided biopsy
revealed metastatic colon cancer.

Case 7

Liver cysts are very common incidental findings on cardiac CT, present in approximately 5% of the general
population. They are usually asymptomatic. They may
be confirmed as purely cystic by ultrasonography. The
differential diagnosis includes parasitic cysts, multiple
cysts in polycystic liver or kidney disease, and cystic
tumors. Usually, cystic tumors have thicker walls and
may have heterogeneous internal content such as blood
and septae.
Transient hepatic attenuation differences are secondary to variant venous drainage within the liver parenchyma and have no pathologic significance. However,
since hepatocellular carcinoma can also fill in on the
portal venous phase CT, an MRI of the liver with contrast is typically advised to confirm the transient hepatic
attenuation difference. The liver is the second most
commonly involved organ by metastases, after the lungs.
The most common primary tumors are from the colon,
stomach, pancreas, breast, and lung.

Case 7 Bone Lesions

A 68-year-old man with chest pain and a history of follicular thyroid carcinoma
underwent cardiac CT (Fig. 22-7).

COMMENTS

n Figure 22-7 Axial computed tomography (CT) reformat


demonstrates a soft-tissue mass (arrow) infiltrating the body of the
sternum. Note the lytic destruction of the bony cortex. The internal
mammary arteries bilaterally seen adjacent to the sternum do not
appear involved. An ultrasound-guided biopsy revealed metastatic
follicular thyroid cancer.

Chest wall bony primary tumors are uncommon,


accounting for 5% of all thoracic malignancies. They
can be benign or malignant and may be of predominantly bony or soft-tissue origin. The most common
benign histology includes fibrous dysplasia, chondroma,
and osteochondroma. Common benign soft-tissue neoplasms include hemangiomas and elastofibromas. Malignant soft tissue masses include liposarcomas, lymphoma,
and metastases from distant tumors, desmoid tumors,
and malignant fibrous histiocytoma. The most common
malignant primary tumors arising from the chest wall
are sarcomas; about 45% originate from soft tissue and
55% from cartilaginous or bony tissue. Chondrosarcomas are the most common primary bone chest wall sarcoma. Bone metastases found on cardiac CT are rare but
important causes of chest pain. They may appear lytic or
sclerotic. The most common primary tumors to metastasize to bone include breast, lung, prostate, kidney,
and myeloma. The spine is a particularly important
structure to assess because of the risk of cord
compression.

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ATLAS OF CARDIAC CT: IMAGING COMPANION TO BRAUNWALDS HEART DISEASE

Case 8

Pulmonary Embolism

In the first case, a 55-year-old woman with recent internal jugular catheter removal
developed acute chest pain and underwent triple rule-out cardiac CT (Fig. 22-8A).
In the next case, a 43-year-old man presented with dyspnea leading to suspicion of
pulmonary embolism (Fig. 22-8B).

n Figure 22-8 A, Axial computed tomography (CT) reformat


demonstrates extensive filling defects in the right lower lobe
segmental arteries (straight arrows), consistent with pulmonary
embolism. More subtle filling defects are present in the left lower
lobe subsegmental arteries (curved arrow), representing left-sided
subsegmental emboli. The source of the embolism is noted in the
right atrium (the tubular filling defect represents thrombus). B,
Axial CT reformat demonstrates a subtle subsegmental pulmonary
embolism in the left lower lobe (curved arrow), and much larger
pulmonary embolisms were identified more proximally (not shown).
Several secondary CT signs of pulmonary embolism can be seen.
Note the right ventricular dilation and flattening of the
interventricular septum (straight solid arrows), indicating increased
right ventricular pressure. Note also the enlarged inferior vena cava
(open arrow). Such findings of increased right heart pressure overload
on CT appear to identify a subset of patients with a worse prognosis.

COMMENTS
CT has replaced invasive pulmonary angiography as the
gold-standard test for the diagnosis of pulmonary embolism. Multidetector CT can visualize pulmonary arteries
down to sixth order pulmonary branches. Some centers
have used cardiac gating to more optimally visualize
the vessels adjacent to the heart without motion artifact.

Case 9

Others have quantified the clot burden on CT and found


it to be associated with both morbidity and mortality
from pulmonary embolism. Specific CT protocols have
been developed to evaluate the pulmonary arteries as
well as the coronary arteries and aorta (triple rule-out
CT). These protocols aim to opacify the pulmonary,
aortic, and coronary circulation in a single acquisition.

The Pleura

A 62-year-old man with chest pain and a persistent left-sided pleural effusion
underwent cardiac CT to exclude coronary artery disease (Fig. 22-9).

COMMENTS
Most benign pleural conditions have a smooth outline.
The most common etiologies include previous infections (pleurisy), hemothorax (look for old rib fractures
on CT), collagen vascular disorders (rheumatoid arthritis), and previous asbestos exposure (pleural plaques).
Benign pleural masses include lipomas, peripheral nerve

sheath tumors, and localized fibrous tumors of the


pleura. Malignant pleural disease is usually nodular in
appearance. It commonly involves the mediastinal as
well as the lateral costal pleura. Although mesothelioma
is the most common malignant tumor of the pleura,
other considerations in the differential diagnosis would
include metastatic adenocarcinoma to the pleura and
lymphomatous infiltration of the pleura.

Chapter 22

Noncardiac Findings Identified on Cardiovascular CT

269

n Figure 22-9 Axial computed tomography (CT) reformat


demonstrates a markedly thickened, enhancing left-sided pleura
and large pleural effusion. Note how both the mediastinal and the
lateral costal pleura are involved (arrowheads), which is a CT sign
strongly suspicious for malignancy. Finally, note the tumor
infiltration of the chest wall (arrows). Tissue biopsy revealed
mesothelioma.

Case 10

The Breasts

A 66-year-old woman presented with chest pain (Fig. 22-10).


CT signs that are most characteristic of malignancy
include irregular margins, irregular shape, and rim
enhancement. Mammography, with or without ultrasonography, is the preferred investigation for breast mass
evaluation, but occasionally CT may offer advantages,
particularly for very large dense breasts or for very deep
lesions close to the chest wall. It also provides a large
field of view. Most breast lesions detected incidentally
on cardiac CT should have definitive evaluation with
mammography to confirm either a benign or malignant
appearance.

SUGGESTED READINGS
The Routine Protocol
n Figure 22-10 Axial computed tomography (CT) demonstrates
a lobulated soft-tissue mass (arrow) in the left breast. The breast
itself appears enlarged and engorged. The skin overlying the breast
is thickened. A biopsy sample of the lesion showed inflammatory
breast carcinoma. Note the left-sided pleural effusion (asterisk).
Thoracentesis revealed malignant cells.

CO MMENTS
Breast lesions are often overlooked on cardiac CT; however, the soft-tissue capabilities of multidetector CT are
sufficient to frequently render confident diagnoses.
Lesions may be characterized as definitely benign, indeterminate, or suspicious and warrant further workup.

Fraser RS, Colman N, Muller NL, Pare PD: Synopsis of Diseases of the
Chest, 3rd ed, Philadelphia, 2005, Elsevier/Saunders.
Hansell DM, Armstrong P, Lynch DA, McAdams HP: Imaging Diseases
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Benign Pulmonary Nodules


Erasmus JJ, Connolly JE, McAdams HP, Roggli VL: Solitary pulmonary nodules: Part I. Morphologic evaluation for differentiation of
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Erasmus JJ, McAdams HP, Connolly JE: Solitary pulmonary nodules:
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Macmahon H, Austin JH, Gamsu G, et al: Guidelines for management
of small pulmonary nodules detected on CT scans: A statement from
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Malignant Pulmonary Nodules


Henschke CI, McCauley DI, Yankelevitz DF, et al: Early Lung Cancer
Action Project: Overall design and findings from baseline screening,
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Henschke CI, Yankelevitz DF, Mirtcheva R, et al: CT screening for


lung cancer: Frequency and significance of part-solid and nonsolid
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Mediastinal Lymphadenopathy
Aquino SL, Hayman LA, Loomis SL, Taber KH: Source and direction
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Sharma A, Fidias P, Hayman LA, et al: Patterns of lymphadenopathy in
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Lung Parenchyma

Mortele KJ, Ros PR: Cystic focal liver lesions in the adult: Differential
CT and MR imaging features, Radiographics 21:895910, 2001.

Bone Lesions
OSullivan P, ODwyer H, Flint J, et al: Malignant chest wall neoplasms of bone and cartilage: A pictorial review of CT and MR findings, Br J Radiol 80:678684, 2007.
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Pulmonary Embolism
Remy-Jardin M, Pistolesi M, Goodman LR, et al: Management of suspected acute pulmonary embolism in the era of CT angiography: A
statement from the Fleischner Society, Radiology 245:315329, 2007.
Schoepf UJ, Costello P: CT angiography for diagnosis of pulmonary
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The Pleura

Fraser RS, Colman N, Muller NL, Pare PD: Synopsis of Diseases of the
Chest, 3rd ed, Philadelphia, 2005, Elsevier/Saunders.
Hansell DM, Armstrong P, Lynch DA, McAdams HP: Imaging Diseases
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Dynes MC, White EM, Fry WA, Ghahremani GG: Imaging manifestations of pleural tumors, Radiographics 12:11911201, 1992.
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Liver Lesions

The Breasts

Kawamoto S, Soyer PA, Fishman EK, Bluemke DA: Nonneoplastic


liver disease: Evaluation with CT and MR imaging, Radiographics
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Harish MG, Konda SD, MacMahon H, Newstead GM: Breast lesions


incidentally detected with CT: What the general radiologist needs to
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