Learning Solutions from

GE Medical Systems
Program Supplement
CT: Cardiac Applications
GEMS 1139
TiP-TV
TM
GE Training in Partnership Television
2002 General Electric Company. All rights reserved.
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TABLE OF CONTENTS
SECTION PAGE
PREFACE
TABLE OF CONTENTS ..................................................................................................................... 2
PRESENTER BIOGRAPHIES ............................................................................................................ 3
PROGRAM OBJECTIVES, TARGET AUDIENCE, AND PRODUCTIVITY STATEMENT .......................... 5
CONTINUING EDUCATION CREDIT ELIGIBILITY .............................................................................. 6
PROGRAM OUTLINE ........................................................................................................................ 7
CARDIAC CT APPLICATIONS............................................................................................................................. 9
BASIC SCANNING PHYSICS ............................................................................................................................ 11
CLINICAL INDICATIONS FOR CARDIOVASCULAR CT................................................................................... 19
CONTRAINDICATIONS FOR CARDIAC CT ...................................................................................................... 21
BETA BLOCKERS.............................................................................................................................................. 22
CONTRAST ENHANCED CARDIAC CT PERFORMANCE............................................................................... 23
DATA PROCESSING ......................................................................................................................................... 35
APPENDIX A: ACRONYMS ............................................................................................................................... 46
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PRESENTER BIOGRAPHIES
Raye Bellinger, MD, MBA, FACC
Dr. Bellinger is a board certified cardiologist and is the regional medical director of Sutter Heart Institute & director of
the Nuclear Center at Sacramento Heart and Vascular Medical Associates. He has been instrumental in establishing
cardiac CT protocols to be used with multidetector scanners for evaluation of coronary artery and other heart
diseases. Educational credentials are as follows: University of Texas, Bachelor of Arts (Microbiology) 1978,
University of Texas Health Science Center at Dallas Southwestern Medical School, Doctor of Medicine 1982,
University of Phoenix, Masters of Business Administration 2000. He completed his internship & residency at the
USAF Medical Center, Keesler AFB, MS in 1985. Additionally Dr. Bellinger is board certified in Internal Medicine,
Nuclear Cardiology and has completed sub-specialty training at Duke University Medical Center in cardiovascular
medicine and interventional cardiac catheterization.
Georg Emlein, MD, FACC
Dr. Emlein is a board certified cardiologist and staff cardiologist at the Sacramento Heart Scan clinic, part of the
Sacramento Heart and Vascular Medical Associates group. In addition to general cardiology, he has worked
extensively with multidetector CT scanners and cardiac CT in particular.
David Dowe, MD
Dr. Dowe is a board certified radiologist and medical director of Atlantic Medical Imaging in Somers Point, New
Jersey. He has worked extensively with cardiac CT applications and multidetector CT systems. His educational
credentials are as follows: LeMoyne College B.S. Biology 1982, Summa Cum Laude, Alpha Sigma Nu. Syracuse
University - MD 1986, Alpha Omega Alpha; Internship and General Surgery residency 1986 1988; Resident
Diagnostic Radiology 1988 1992, Chief Resident 1990 1991.
DeAnn Haas Global CT Marketing Manager / Cardiac Applications
DeAnn has worked for General Electric Medical Systems (GEMS) for 6 years. She holds a bachelors degrees in
Radiologic Technology and Business and is a registered technologist in radiography, computed tomography, and
magnetic resonance. Her clinical experience includes ten years as a technologist in CT and X-ray.
DeAnn began her career at GEMS as a clinical product development specialist in the X-ray modality. She eventually
moved to CT Marketing as the clinical product development specialist for cardiac products including SmartScore,
SnapShot Imaging, CardIQ Analysis, and CardIQ Function. She is currently the Global Cardiac CT Marketing
Manager for LightSpeed cardiac applications.
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PRESENTER BIOGRAPHIES, Continued
Roger Beck CT Program Manager, Customer Learning Technologies
Roger, from Madison, Wisconsin, has been with General Electric Medical Systems for 11 years. Roger holds
bachel or' s and mast er' s degrees i n Publ i c Admi ni st rat i on and Management f rom t he Uni versi t y of
Wisconsin-Madison and Cardinal Stritch College in Milwaukee. He is also a registered radiologic technologist and
registered CT technologist with the American Registry of Radiologic Technologists.
His clinical background includes several years working as a special procedures technologist, which included work in
computed tomography, catheter angiography, and interventional procedures. After attaining a master's degree, he
worked as a radiology manager responsible for technical operations and quality improvement.
Roger began his career with GE Medical Systems as a CT Clinical Educator where he co-developed and taught the
HiLight and HiSpeed Advantage customer classes. He is now Program Manager for TIP-TV's CT broadcast network.
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PROGRAM OBJECTIVES, TARGET AUDIENCE, AND PRODUCTIVITY STATEMENT
Program Objectives
By the end of this program, the viewer should be able to:
Perform a Cardiac CT from start to finish including acquisition and post processing.
Describe the indications and contraindications for Cardiac CT.
Recognize cardiac anatomy and physiology.
Review cardiac CT image appearance and interpretation fundamentals.
Target Audience
Course objectives for this program specifically target technologists, radiologists, and cardiologists who are planning
to use LightSpeed CT products for cardiovascular imaging. While not limited to this audience group, the technical
content will be most effective when applied to people with this training.
NOTE: Viewers who apply for continuing education (CE) credit and meet the application requirements are eligible for
credit, regardless of their audience status.
Productivity Statement
This program was developed to enhance your professional and educational level, and increase your productivity and
skills.
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CONTINUING EDUCATION CREDIT ELIGIBILITY
IMPORTANT NOTICE!
You may only receive continuing education (CE) credit once for a particular course, regardless of the format in which
it was viewed. This GE Medical Systems TiP-TV course may be available in several different formats, such as, but
not limited to, an Online Web course or videotape.
If you have already applied for and/or received CE credit for this course, you are NOT eligible to receive CE credit for
this TiP-TV broadcast. Contact your CE accreditation organization for additional information as needed.
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PROGRAM OUTLINE
CT: Cardiac Applications
I. Cardiac CT Applications
A. What is Cardiovascular CT?
B. Calcium Scoring (SmartScore)
C. SnapShot Imaging
D. CardIQ Analysis
E. CardIQ Function
II. Basic Scanning Physics
A. Electrocardiography (ECG/EKG)
B. Gating Techniques
C. Reconstruction Techniques for Cardiac CT Angiography
III. Clinical Indications for Cardiovascular CT
A. Risk Assessment
B. Diagnosis of Heart Disease
C. Follow-up Interventional Stent and Bypass Procedures
D. ER Chest Pain
E. Electrophysiology Applications
F. Coronary Sinus Mapping
IV. Contraindications for Cardiac CT
A. Heart Rate Limitations
B. Biventricular Pacemakers
C. Cardiac Arrhythmias
D. Contrast Media Allergies
V. Beta Blockers
VI. Contrast Enhanced Cardiac CT Performance
A. Patient Preparation
B. Scan Preparation
C. Breathing Parameters
D. Cardiac Scanning
E. Low Dose Helical Series or SmartScore Acquisition (Optional)
F. Cardiac Helical SnapShot Protocols
G. SnapShot Burst
H. SnapShot Burst Plus
I. Retrospective Reconstruction
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PROGRAM OUTLINE, Continued
VII. Data Processing
A. CardIQ Analysis
B. CardIQ Function
C. Terms and Definitions for Cardiac Functional Analysis
D. Output Graphics and Contours Needed
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CARDIAC CT APPLICATIONS
WHAT IS CARDIOVASCULAR CT?
Cardiovascular CT is the application of computerized tomography (CT) to acquire motion-free images of the heart.
Because of the continuous beating motion of the heart, we engage the use of an electrocardiography (ECG) monitor
enabling image reconstruction to be gated to any point along the R-R interval of the heart cycle. (The R wave is part
of the QRS complex which represents the ventricular depolarization phase of the cardiac cycle. An explanation of this
cycle will be presented below). Gating is an important part of the imaging process that allows us to "freeze" heart
motion in order to clearly visualize coronary arteries.
CALCIUM SCORING (SMARTSCORE)
Calcium scoring is a non-enhanced application used to assess the amount of calcified plaque within coronary
arteries. A calcium scoring exam can be performed with a CT scanner that has the ability to do sub-second scanning
and has gating capabilities. The images are acquired using retrospective or prospective gating, depending on the
capabilities of the CT system. Typically, 3 mm slice width images are acquired throughout the heart in a single breath
hold. Images are then transferred to the Advantage Windows workstation for processing and report preparation. The
following General Electric Medical Systems (GEMS) CT scanners can perform calcium scoring (if they have a sub-
second scan option):
HiSpeed X/i Single Slice Scanners
HiSpeed NX/i Dual Slice
HiSpeed CT/i Single Slice
HiSpeed QX/i Four Slice
LightSpeed QX/i Four Slice
LightSpeed Plus Four Slice
LightSpeed Ultra Eight Slice
LightSpeed
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Sixteen Slice
NOTE: This presentation does not focus on calcium scoring, but will contain references to it during the course of the
program.
SNAPSHOT IMAGING
SnapShot Imaging is a contrast enhanced cardiac application to create angiographic images of the coronary vessels
and chambers using retrospective gating. This acquisition technique also allows for Functional analysis of the heart.
A SnapShot exam can be performed on a Multi-slice GEMS CT scanner that has at least Four Slice Technology,
0.5 secs gantry rotation, and gating capabilities.
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SnapShot images are acquired using retrospective gating, and depending on the heart rate, will use one of the
following reconstruction techniques:
SnapShot Segment
SnapShot Burst
SnapShot Burst Plus
Typically, a 0.625 mm slice width is used with the LightSpeed
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system in order to scan the heart in a single
breathhold (1.25 mm on LightSpeed Plus and Ultra). These factors optimize visualization of the heart by providing
exquisite detail and artifact-free images. The following GEMS CT Systems are capable of performing SnapShot
Imaging:
LightSpeed Plus Four Slice
LightSpeed Ultra Eight Slice
LightSpeed
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Sixteen Slice
CARDIQ ANALYSIS
CardIQ Analysis is a dedicated cardiac post processing tool which aids a physician in the diagnosis cardiovascular
disease. Within this software suite is a set of fast post-processing tools that can be used to easily visualize cardiac
anatomy, coronary vessels, congenital anomalies, bypass graft patency, in-stent stenosis, anomalous coronary
vessels, and the complete cardiovascular system. CardIQ Analysis resides on the Advantage Workstations 3.1 or
higher.
CARDIQ FUNCTION
CardIQ Function is a dedicated cardiac post processing tool which aids a physician in the functional assessment of
the heart. Within the software suite, the user can accurately quantify left and right ventricular volumes, ejection
fractions, myocardial mass, wall motion, and wall thickness. CardIQ Function resides on the Advantage Workstation
4.0 and higher.
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BASIC SCANNING PHYSICS
In this section, well describe how images are acquired using an ECG machine with both prospective and
retrospective gating. Well also explain how images are created for contrast-enhanced cardiac imaging with
SnapShot reconstruction techniques.
Temporal Resolution a measure of the length of time it takes to acquire an image. For example, a 0.5 sec rotation
full scan (360 degrees) has a temporal resolution of 0.5 sec (500 msec).
In order to provide motion-free imaging of coronary vessels, we need to improve temporal resolution by reducing
acquisition times to a value below 500 msec. We do this using the following techniques:
Half scan reconstruction
ECG gating
SnapShot Segment, SnapShot Burst, and SnapShot Burst Plus reconstruction
Half Scan Reconstruction
The minimum amount of data required to reconstruct one slice is 180 degrees plus the fan angle of the beam. By
using half scan reconstruction techniques, we can improve the temporal resolution of the image from 500 msec to
250 msec plus the fan angle. This results in an image with 330 msec temporal resolution.
NOTE: All CT Vendors quote temporal resolution with respect to a half scan only in their marketing information. They
do not include the fan angle in the quoted figure. At GEMS, we annotate temporal resolution to include fan
angle.
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ELECTROCARDIOGRAPHY (ECG/EKG)
An electrocardiogram is a recording of electrical conductivity of the heart. The components of an ECG trace are
P wave
QRS complex
ST segment
T wave
The patient is connected to several electrodes (for GEMS Cardiac CT there are four) that will produce an ECG trace
or waveform on the display monitor.
P wave represents atrial depolarization resulting in contraction of the atria.
QRS complex represents ventricular depolarization and results in contraction of the ventricles (systole). The R
wave is used for triggering because of its strong electrical signal and correlation to the muscular activity of the heart.
ST segment appears as a straight, level line between the QRS complex and the T wave. Elevated or lowered ST
segments may indicate the heart muscle is damaged or is not receiving enough blood.
T wave represents repolarization of the ventricles and results in relaxation of the ventricles (diastole).
GATING TECHNIQUES
Prospective Gating
In a prospectively gated acquisition, the patient is connected to an ECG machine which is further connected to the
CT system. The x-ray beam is turned on and off based on the triggering of the R peak. The user defines a %R peak
delay for x-ray on and chooses whether one, three, or five images are captured during the hearts diastolic phase.
Prospective gating is employed for calcium scoring exams (SmartScore) on the GEMS HiSpeed QX/i and LightSpeed
CT systems. This x-ray triggering technique uses a lower radiation dose protocol than that used for retrospective
gating.
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Prospective gating uses cine scan technique, which entails continuous scan acquisition with no table incrementation.
As we employ this technique in multislice (multidetector) scanners (4, 8, 16) a range of locations are collected in any
one heart beat.
To understand the graph above, the user will first need to know some key terms.
R to R interval is the time between the peak of one R wave and the peak of the next. Each R to R interval
represents the length of one cardiac cycle.
Trigger Delay is the time delay before x-ray exposure to capture an image.
In the systolic phase, the heart contracts to force blood out of the heart.
In the diastolic phase, the heart relaxes and fills with blood.
For an example of how this graph works, well explain prospective gating in a patient with a 60 beat per minute (BPM)
heart rate. This heart rate has an R-R interval of 1000 msec. In this example, lets assume well generate one image
per R-R cycle. The x-ray beam would be turned off from 0 msec to 574 msec, turned on at 575 msec, and stay on
until 825 msec. It would then shut off and the table would move to the next location to prepare for another cine scan
sequence (cine all images are acquired at the same table location). While the table is moving to the next scan
location, a heart beat will be skipped. The image generation process is repeated at the new location.
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The above diagrams demonstrate the prospective gating interface for the LightSpeed scanner. This procedure is
mainly used for calcium scoring (SmartScore). On a scanner with a 0.5 second acquisition speed, we recommend
you do one image per R-R interval as long as the heart rate is steady. When the heart rate is variable, we
recommend a selection of three images per R-R interval.
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Initially, you can select the number of images you wish the system to generate per heart cycle, then you select the
time duration from the acquisition of one image to the next in milliseconds, if you have selected more than one image
per heart cycle. As a rule of thumb, we recommended you select 50 msec between images.
For an example of how this graph works, well demonstrate with a patient whose heart rate is 60 BPM. The example
assumes three images per R-R cycle are to be generated. A 60 BPM heart rate has an R-R interval of 1000 msec.
The X-ray beam would be turned off from zero msec to 524 msec, turned on at 525 msec to remain on until 875 msec
when it then shuts off.
The initial cine acquisition is complete so the table moves to the next location. While the table is moving, a heart beat
is skipped. The scan process is repeated at the new location in the next heart beat. With the three-image acquisition
setup, the system collects overlapping information (image one spans from 525 msec to 775 msec, image two from
575 msec to 825 msec, and image three from 625 msec to 875 msec).
Retrospective Gating
In a retrospectively gated acquisition, the patient is connected to the ECG machine, which is further connected to the
CT system. When the procedure takes place, x-ray exposure is continuous while ECG information and scan data are
collected throughout the entire R-R interval for every location in the heart. This is performed during a single breath
hold.
Retrospective gating provides the capability to shift the center of the image within the R-R interval by selecting a %R
(or phase) to which the reconstruction will be centered. Retrospective images can be selected and reconstructed at
any %R. Routinely we recommend a value of 70% to 80% with a 5% increment for coronary artery imaging. For
cardiac functional analysis, 5% to 95% with a 10% increment is recommended.
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RECONSTRUCTION TECHNIQUES FOR CARDIAC CT ANGIOGRAPHY
SnapShot Segment
This is a retrospectively gated technique using half-scan reconstruction to process an image within one cardiac cycle
at a given slice location. We recommend the use of SnapShot Segment for patients having a heart rate range
between 40 to 60 BPM. SnapShot Segment provides images with a temporal resolution of 250 msec (excluding fan
angle) at a 0.5 sec rotation speed.
The images below illustrate SnapShot Segment on the LightSpeed Ultra (eight slice scanner). When using the
LightSpeed
16
, all 16 detector rows are activated to collect scan data.
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SnapShot Burst
This is a retrospectively gated technique using half scan reconstruction to process an image from up to two cardiac
cycles within the same heart phase at a given z-location. Utilizing this technique, can bring the temporal resolution in
the image down to as low as 125 msec (excluding fan angle) for some heart rates when scanned at a 0.5 second
gantry rotation speed. We recommend the use of SnapShot Burst for patients who have a heart rate range between
60 75 BPM.
NOTE: The images below illustrate SnapShot Burst on the LightSpeed Ultra (eight slice scanner). When using the
LightSpeed
16
, all sixteen detector rows collect signals during gantry rotation.
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SnapShot Burst Plus
This is a retrospectively gated technique using half-scan reconstruction to process an image from up to four cardiac
cycles within the same heart phase at a given z-location. Utilizing this technique can bring the temporal resolution of
the image down to as low as 65 msec (excluding fan angle) for some heart rates. We recommend the use of
SnapShot Burst Plus for patients who have a stable heart rate range between 76 and 110 BPM.
When acquiring images for patients within the 76 110 BPM heart rate range, the rotational speed of the gantry is
changed, affecting temporal resolution. For heart rates between 76 and 90 BPM, we rotate at 0.6 sec; for heart rates
>90 BPM, we rotate at 0.5 sec.
NOTE: The images below illustrate SnapShot Burst Plus on the LightSpeed Plus (four slice scanner). When using
the LightSpeed
16
, all sixteen detector rows collect signals during gantry rotation. When using the LightSpeed
Ultra, eight rows of data are collected per rotation
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CLINICAL INDICATIONS FOR CARDIOVASCULAR CT
There are differing clinical indications for non-invasive cardiovascular CT which may become routine in your clinical
setting. Following is a list of examination indications currently in use; there will certainly be more as the technique
evolves.
RISK ASSESSMENT
Coronary artery disease (CAD) accounts for well over 500,000 deaths annually in the United States. A unique
technique to determine CAD risk is coronary calcification scoring. Coronary artery calcification scoring is used to
determine the presence of early coronary artery disease and the extent of plaque burden, but does not locate
stenosis in a coronary artery.
When looking at the calcium score to determine risk, a physician will look at the total calcium score and place the
patient in a risk category. A calcium score of zero indicates absence of calcium and a low likelihood of obstructive
CAD. In most studies, a score less than ten also indicates a low likelihood of CAD. A calcium score greater than 400
implies the presence of extensive CAD and indicates follow-up is necessary. A score between ten and 400 indicates
moderate plaque burden. Studies indicate these patients should be counseled about risk factor modification, exercise
testing, and future risk stratification testing.
DIAGNOSIS OF HEART DISEASE
There are many possible diagnoses of heart disease, but the main pathological process is coronary artery disease
(CAD). CAD is the number one killer in the United States affecting more than 12 million Americans. Coronary artery
disease refers primarily to atherosclerosis within the walls and lumen of the artery. The arteries become stenotic
(narrowed), restricting blood flow to the heart. When a patient exhibits symptoms of coronary artery disease, there
are many diagnostic tests available to them, one of which is cardiac catherization to visualize arterial stenosis. With
the development of multidetector computed tomography (MDCT) and the LightSpeed
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, we are now able to
non-invasively visualize coronary arteries to evaluate disease.
FOLLOW-UP INTERVENTIONAL STENT AND BYPASS PROCEDURES
In today's practice, if a patient has had coronary bypass graft surgery or stent placement and demonstrates further
chest discomfort theyll often need a repeat cardiac catheterization to evaluate restenosis. With the development of
MDCT, these complications can easily be assessed with a non-invasive study.
Note: Visualization of the stent lumen is currently being evaluated with the LightSpeed
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using sub-millimeter slice
thicknesses. Its future is promising as clinical evaluation continues.
ER CHEST PAIN
When a patient arrives in the emergency room (ER) with chest pain, many procedures are immediately performed.
With the LightSpeed
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, a new examination may be considered. It is called a gated chest CT scan. The procedure
allows the user to scan from the apices to the diaphragm with gating allowing visualization of the aorta, the
pulmonary arteries, and coronary arteries in one study. (Gating is a technique used to trigger imaging at optimum
positions within the cardiac cycle). This exam is currently being evaluated by multiple medical centers and may prove
to be an important new diagnostic test.
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ELECTROPHYSIOLOGY APPLICATIONS
Atrial fibrillation is a condition where there is disorganized electrical conduction within the atria, resulting in ineffective
atrio-ventricular blood transfer. An ablation procedure has been designed to treat atrial fibrillation by diminishing the
hearts electrical signal. Multislice CT can help in the planning of these ablation procedures by segmenting out the left
atrium to give the electrophysiologist a view of the atria and pulmonary veins.
CORONARY SINUS MAPPING
In a patient experiencing heart failure, the right and left ventricles will often not pump in unison. Treatment will include
a biventricular pacemaker, which is placed to send a small electrical impulse through the leads. The LightSpeed
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MDCT scanner provides capability for a new procedure to help guide the placement of these leads. The procedure is
"coronary sinus mapping" which visualizes the coronary sinus and helps determine the size and curvature of the
vessel.
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CONTRAINDICATIONS FOR CARDIAC CT
While multidetector CT is an excellent tool for diagnosis of cardiac disease, there currently are some limitations to the
technology. The following limitations will be discussed:
Heart rate
Biventricular pacing
Cardiac arrhythmias
Contrast media allergies
HEART RATE LIMITATIONS
With the use of multidetector technology, the current heart rate range which can be scanned lies between 40 beats
per minute (BPM) to 110 BPM. The procedure is contraindicated for patients who do not fall within this range because
image quality is compromised. Heart rate limitations are further explained in the beta blocker and physics
discussions.
BIVENTRICULAR PACEMAKERS
A biventricular pacemaker (dual-chamber pacemaker) consists of a pulse generator and wires connected to the right
atrium and the right ventricle in order to sense the hearts own pacemaker signal (sinus node). With this pacemaker
in position, current CT technology cannot gate the scan acquisition properly. For this reason, we do not recommend
scanning these patients.
NOTE: The physician may feel comfortable shutting off one of the leads for the duration of the study. This is not
recommended by General Electric Medical Systems (GEMS); an on-site physician would need to determine
if this technique is necessary to complete the study.
CARDIAC ARRHYTHMIAS
Arrhythmia refers to any abnormal cardiac rhythm. Patients with severe arrhythmia conditions should not be scanned
with CT due to generation of temporal resolution artifacts.
CONTRAST MEDIA ALLERGIES
As with any enhanced CT study, patients should be excluded if they have a known allergy to contrast media. Routine
exclusion screening questions should be used to determine the patients risk factors prior to the CT examination.
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BETA BLOCKERS
A beta blocker is a medication used to reduce the work load of the heart by providing a slow and steady heart rate
that allows the heart to function more efficiently.
To obtain diagnostic image quality in enhanced cardiac CT exams, some institutions use beta blockers on a routine
basis. This is not a mandatory requirement, and in fact, many places choose not to use them for cardiac CT.
NOTE: GEMS offers three heart rate-based scanning techniques within the SnapShot scanning protocol for selection
within the beat per minute range between 40 and 110.
Below are two examples of beta blocker protocols in use at cardiac imaging clinical sites.
Dr. Raye Bellinger, Sacramento Heart Scan, Sacramento, California
The patient takes 50 milligrams (mg) of Metoprolol the night before the examination (oral medication).The following
morning the patient again takes 50 mg of Metoprolol. During performance of the examination, more medication may
be administered as needed.
Dr. David Dowe, MD Atlantic Medical Imaging, Somers Point, New Jersey
At scheduling time, the patient is asked about medication history and whether there is any contraindications to beta
blockers. If the patient has not been taking beta blockers previously, 40 mg of Inderal is administered orally one hour
prior to the examination. The patient's heart rate is checked one hour after the medication has been given. At this
time if the heart rate is greater than 70 BPM, another similar dose of Inderal is given.
NOTE: GEMS cannot prescribe medications. The above recommended protocols are derived from physicians at
individual medical sites and should be used as guidelines only. It is recommended that the patient discuss the
use of beta blockers for diagnostic cardiac CT angiography with a cardiologist at the facility. There are
contraindications for and can be reactions to beta blockers. Each medical facility should ensure adequate
emergency procedures and medications are readily known and available.
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CONTRAST ENHANCED CARDIAC CT PERFORMANCE
PATIENT PREPARATION
Proper patient preparation is essential to obtaining a quality cardiac exam. When a patient is scheduled, he or she
should be directed to fast four hours prior to the study because intravenous contrast media will be used. In addition,
the patient should be advised not to consume any caffeinated substance 12 hours prior to the study. Caffeine can
raise heart rates which can often compromise the cardiac exam. In order to keep the heart rate as low as possible,
the patient should be advised to not engage in exercise prior to the examination.
When the patient arrives, it is important to explain the exam:
Bring the patient into the room and have him/her lie on the table. Explain how the patient will be connected to an
electrocardiography (ECG) machine for heart rate monitoring
Explain proper breathing instructions and patients should practice before the exam
Explain that the patient will be receiving an injection of intravenous contrast material. Check with the patient to
see if the individual has had contrast injections previously and explain the sensations one may experience, such
as warmth and metallic taste
Coach them to relax during the procedure. Proper explanation allows the patient to remain calm throughout the
procedure. This also helps to keep heart rates low
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SCAN PREPARATION
Have the patient lie supine and feet-first on the table with a cushion under the knees. Load the injector with 120 to
150 cc of contrast material (300-350 milligrams of iodine per milliliter - mgI/ml). Then, start an intravenous line in the
patients antecubital fossa, if possible. Either arm is alright, although some practitioners recommend use of the right
arm to reduce streaking.
Raise the patients arms above the head and place them on the pillow. Place the ECG leads on the patient as
displayed in the figure below. (If the leads are placed while the patients arms are down, they may later move up over
the clavicles when they are raised above the head causing gating issues.)
NOTE: Hair on the chest will need to be shaved before placing the leads. Also, make sure to use new leads; old or
expired leads may cause intermittent triggering.
Once the leads are placed on the patient, turn on the ECG machine and make sure there is an optimal signal.
BREATHING PARAMETERS
The patient should be given hyperventilation instruction for each scan sequence. Hyperventilation lowers the heart
rate and allows the patient to breathhold for the entire exam. When setting up, it is recommended you program
hyperventilation into the scan prescription for consistent breathing instructions. When creating this voice message,
make sure to breathe your patient slowly, an average hyperventilation should take about 17 seconds. On the last
breathhold be sure to state "hold your breath" and program three seconds of silence to confirm the voice. This will
give the patient enough time to breathhold before the scan begins.
A recommended hyperventilation protocol sequence asks the patient to take a breath in, blow it out, take in another
breath, blow it out, then take in a breath and hold it.
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CARDIAC SCANNING
The following protocol should be used when scanning a cardiac exam:
Scout
Landmark the sternal notch
Select "New Patient" and enter patient data
Select the anatomical area (Chest) and select one of the snapshot protocols
Selection of the snapshot (cardiac) protocol from the main menu.
Take the scout views anteroposterior (AP) and lateral (Lat) be sure to use the hyperventilation protocol for scout
scans and all scans to follow.
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Monitor and take note of the heart rate for all scouts. If the heart rate is not displayed on the screen, click the red box
"Heart Rate" to activate the heart rate monitoring on the operators console (OC) screen.
Scout screen using no active gating
Scout view screen showing heart rate values in beats per minute (refreshes every two heart cycles).
When the scouts are finished, select "Next Series" to display the next step of the protocol.
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LOW DOSE HELICAL SERIES OR SMARTSCORE ACQUISITION (OPTIONAL)
At this time, you may wish to perform a non-contrast scan series. This provides the ability to define the start and end
locations for the post contrast cardiac acquisition. Some diagnostic centers utilize a low-dose helical run while others
may prefer to perform a calcium scoring series for this purpose.
Low Dose Helical Protocol (Optional)
Scan Type Helical
Rotation Time 0.5 secs
Start Location S0 (Obtain from scout)
End Location I120 (Obtain from scout)
Coverage Base to apex of heart
Reconstruction interval 5 mm
Slice thickness 5 mm
Scan field of view (SFOV) Large
Display field of view (DFOV) 25 cm
kVp - 120
mA 40
SmartScore Protocol (Optional)
Gating on
Scan type Cine
Interscan delay (ISD) 1.0
Reconstruction Segment
Recon Type Standard
Trigger Delay 70%
Images per R-R Interval 1
Rotation time 0.5 secs
Start location S0 (Obtain from scout)
End location I120 (Obtain from scout)
Coverage Base to apex of heart
Reconstruction interval 1.25 or 2.5 mm
Slice thickness 1.25 mm / 16i 2.5 mm / 8i
SFOV Large
DFOV 25 cm (Do not change)
kVp 120
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mA 200
When the non-contrast series is completed, select the "Next Series" soft key to display the next step of the protocol.
Timing Bolus
A timing bolus is used to see the exact arrival time of contrast to the coronary arteries. Here is the protocol.
Scan Type Axial
Monitor location Root of aorta near left main coronary artery (LMA) takeoff
Rotation Time 0.8sec
Start location S0
End location S0
Interval 0
Slice thickness 5 mm
Prep delay 5 sec
ISD 1.2 sec
SFOV Large
DFOV 25
kVp 120
mA 40
Number of slices 12
Contrast amount 20 cc
Injection rate 4 cc/sec
View the scout and place the line at the base of the heart, usually one centimeter (cm) below the carina
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Time Bolus Tracking
Scan the patient with the hyperventilation protocol and note the heart rate during the scan
Performing an MIROI to Display the Timing Bolus Parameters
MIROI multiple image region of interest
ROI region of interest
After the images are reconstructed, highlight the view port in which they are contained, select "Measurements," and
then "MIROI." Place the ellipse ROI on the ascending aorta, and size it to fit completely within the aorta.
Count each tic line to the peak of the curve, and determine the time to peak (remember image number one takes
place at five seconds and the tic marks are two seconds apart). Once youve determined the time to peak
enhancement, add three seconds (because the contrast still needs to get to the coronary arteries); this is now the
pre-scan delay. This bolus time is a key parameter to use for gated cardiac acquisition.
Cardiac Helical Exam
After the timing bolus is complete, the cardiac helical series is the next sequence to be performed. During the
pre-scan (scout, low dose helical and timing bolus), you have been monitoring the heart rate to determine scan
acquisition parameters. Below is a chart to determine scan acquisition parameters from which to decide.
Once the acquisition mode is determined, you can start the cardiac exam.

Heart Rate
40-60 BPM

SnapShot
Segment


Heart Rate
60-75 BPM


SnapShot
Burst

Two-sector Recon mode

Heart Rate
76-90 BPM
90-110
BPM


SnapShot
Burst Plus


Four-sector Recon mode. This reconstruction method
requires a stable heart rate (within 10BPM). If not stable -
use SnapShot Burst mode instead. You may not get
adequate image quality to view all segments of the
coronary arteries in this case
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CARDIAC HELICAL SNAPSHOT PROTOCOLS
Below is an example of the "View Edit SnapShot Segment Screen" for heart rates between 40 60 BPM.
Scan Type Cardiac Helical
Cardiac Mode SnapShot Segment
Rotation Time 0.5 sec
Start Location S0 (based from the Scout Scans)
End Location I120 (based from the Scout Scans)
Coverage Base to apex of heart
Slice Thickness 0.625 mm or 1.25 mm
No overlap (artifacts will result if overlap is prescribed)
SFOV Large
DFOV 25 (Adjustable as desired to contain coronary arteries)
Pitch heart rate dependent
Reconstruction phase 75% (use the "Gating" button)
kVp 120
mA 370 400 (0.625 mm) / 300 320 (1.25 mm)
Enter in the prep delay based on the timing bolus
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Gating Override Button
For SnapShot Segment, the user can override the detected heart rate. This would be done if the heart rate drops
more than five BPM and the system does not detect it. In this instance, select the "Gating" button, turn "Heart Rate
Override" on, and key in the heart rate observed in the non-contrast series during breathhold.
NOTE: When confirming the patient's heart rate make sure to monitor the "Gating" button and select the "Confirm"
key when the appropriate heart rate is demonstrated based on your observations. If the patient had a premature
ventricular contraction (PVC) at "Confirm" with the heart rate suddenly jumping up to 90 BPM, this would be
the pitch setting for the entire acquisition. Image quality would be severely compromised should this happen.
Once you have planned the appropriate scanning protocol and range
Arm the injector with the remaining contrast (125 to 135 cc at 4 cc/second Caution: the injection rate has to be
the same as the bolus test rate)
Ensure the ECG monitor is ready for the scan
Use the hyperventilation protocol
Initiate the scan
Note: On bypass graft follow-up exams, the scan needs to cover the entire graft. Usually, you can start just above the
arch of the aorta and scan through the apex of heart. However, it is recommended you get a procedure report to see
where the bypass vessels were placed, or be certain to scan above the clips on the scout view.
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Points to consider when selecting SnapShot Segment
Pitch Chart for SnapShot Segment Based on the BPM for LightSpeed
16
Pitch: 0.275 to 0.325 (normalized) based on heart rate. The pitch should automatically be detected (based on the
heart rate once the confirm key is selected). Make sure to confirm the prescription at the accurate heart rate to
ensure the correct pitch is assigned. When the prescription is confirmed, the system will assess the heart rate, round
it to the nearest multiple of five, and set the pitch based on a heart rate five BPM lower.
Example # 1: A heart rate of 56 BPM will be rounded to 55 BPM and then dropped to 50 BPM for pitch setting during
helical acquisition
Example # 2: A heart rate of 53 BPM will be rounded to 50 BPM and then dropped to 45 BPM for pitch setting during
helical acquisition
The annotation on the image in the upper right hand corner is SSEG.
SNAPSHOT BURST
Scan Type Cardiac Helical
Rotation Time 0.5 second
Start Location S0 (based from the Scouts)
End Location I120 (based from the Scouts)
Coverage Base to apex of Heart
Slice Thickness 1.25 mm / 0.625 mm
No overlap (if overlap is done, artifacts may result)
SFOV Large
DFOV 25 (Adjustable as desired to contain coronary arteries)
kVp 120
mA 370 400 (0.625 mm) / 300 320 (1.25 mm)

Heart Rate
(BPM)


Gantry Rotation
(Sec)

LightSpeed
16
Pitch


40

0.5

0.275:1

45


0.5


0.3:1


50


0.5


0.325:1


55


0.5


0.325:1


60

0.5

0.325:1
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Pitch 0.3:1 (fixed)
Enter in the prep delay based on the timing bolus
Points to consider when selecting SnapShot Burst
SnapShot Burst is a multi-sector protocol which uses up to two sectors (heart beats) to reconstruct each image.
Pitch: Constant at 0.3:1 in Burst mode. This is to ensure adequate overlapping to allow two x images per heart cycle.
The operator will not be able to alter the pitch selected when the SnapShot Burst protocol is selected.
In order to get the best images possible in Burst mode, scan using the SnapShot Burst protocol. (You can scan with
SnapShot Segment and retrospectively reconstruct to Burst from 50 60 BPM. Images derived in Segment mode
must be acquired at a pitch greater than 0.3:1.
NOTE: With heart rates below 60 BPM, we have not seen improvement in image quality with Burst reconstruction.
However, if an artery is affected by motion artifact, the user can use Burst in Retrospective Reconstruction to
improve image quality.
SnapShot Burst reconstruction relies on data coherency between adjacent cardiac cycles. It is also more susceptible
to artifacts due to beat-to-beat variations.
The annotation on the image in the upper right hand corner is SSB.
SNAPSHOT BURST PLUS
Scan Type Cardiac Helical
Rotation Time 0.6 (75 90 BPM)
Rotation Time 0.5 (<75 BPM & >90 BPM)
Pitch fixed at 0.275:1
Start Location S0 (based from Scouts)
End Location I120 (based from Scouts)
Coverage Base of Heart to Apex
Slice Thickness
1.25 mm LightSpeed Plus and LightSpeed Ultra
0.625 mm LightSpeed
16
No overlap (overlap may produce artifact)
SFOV Large
DFOV 25 (Adjustable as desired to contain coronaries)
kVp 120
mA 300 LightSpeed Plus and LightSpeed Ultra / 350 mA LightSpeed
16
(you may need to use a little more mA
for large patients)
Enter in the prep delay based on the timing bolus.
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Points to Consider when Selecting SnapShot Burst Plus
SnapShot Burst Plus should be used with patients who have stable heart rates (within 10 BPM) in the 75 90 BPM or
90 to 110 BPM ranges. Reconstruction relies on data coherency between adjacent cardiac cycles. It is also more
susceptible to artifacts due to beat-to-beat variations.
SnapShot Burst Plus is a multi-sector protocol which uses up to four sectors (heart beats) to reconstruct each image.
The heart rate "Override" button will be red when entering this protocol. You need to key in the BPM for every patient
series in Burst Plus mode. (That value will be noted on the non-contrast and timing series under breathhold
conditions).
Select the "Gating" button and enter the BPM value for the patient. This button will remain red until you complete this
step.
The annotation on the image in the upper right hand corner is SSB4, SSB2, or SSEG (see Back off Logic Image
Reconstruction for an explanation of image annotation).
RETROSPECTIVE RECONSTRUCTION
Once the scan is completed, select "Retro Recon."
Select the "Phase" button and process the images from 70
80% of the R-to-R interval with an incremental step of five in
the image acquisition mode used to acquire the images. The
images (displayed as a complete series) will be used if the
heart is not frozen at 75% of the R-to-R interval from the
initial scan. The images can also be processed from any
point within the R-to-R interval (0 to 99%). This is done if you
would like to see images from systole to diastole.
Reconstruction modes can be altered by choosing gated helical (Segment, Burst, Burst Plus) and ungated segment
options.
When doing 0.625 mm slices on large patients, the exposure parameters may generate images that are noisy. In this
case, you can retrospectively reconstruct the images to a 1.25 mm image to improve image quality. Select the "Image
Thickness" button and change the thickness from a 0.625 mm slice to a 1.25 mm image.
When confirmed, click on "Accept" button.
NOTE: If you have CardIQ Function software for Quantitative Analysis youll need to reconstruct the series from
5 95% R-R at an increment of 10% for further analysis.
For ease of use, you are advised to reconstruct the 70 80% R-R data at an increment of 5% for coronary vessel
post processing first, then reconstruct the above function data set (5 95% at 10% increment). All reconstructed
images are saved to the same series. You can click and drag in the Browser "Image Selector" to highlight the images
to be used for analysis before launching the protocol.
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DATA PROCESSING
CARDIQ ANALYSIS
CardIQ Analysis is an Integrated Cardiac Post Processing Environment. It is housed in the Advantage Windows
Workstation within the Volume Analysis program. Images are transferred from the LightSpeed CT system to the
workstation and can be processed using any of the available dedicated protocols for contrast enhanced cardiac CT
images. The software, once loaded, can be launched through "Volume Analysis" or "More Software" from the
browser. There is a suite of protocols to choose from with the ability to process both single phase (SP) and multi-
phase (MP) cardiac data sets.
NOTE: Upon delivery, in addition to your CardIQ Analysis software you will find an Operator Manual and a Quickstep
User Guide. This guide is a pictorial step-by-step booklet to help you work through all of the protocol options
within CardIQ Analysis
Key Features
One-Touch Coronary 3D Vessel Tree
These protocols provide the user with a 3D view of vasculature.
There are three Vessel Tree protocols designed for image generation. The first is a maximum intensity pixel
(MIP) view of blood vessels with major blood pool structures removed (ventricles, atria).
The second and third Vessel Tree Protocols are volume rendering (VR) protocols that will remove everything
except the ascending aorta with the coronary arteries attached.
There is a pop-up wizard that instructs the user to place a curser at the aorta near the level of the Left Main
Artery (LMA) ostium. From this single seed, the vessel tree is created.
All routine 3D tools are still available while using this protocol.
There are Single Phase (SP) and Multi-Phase (MP) Vessel Tree protocols available.
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Multimedia (JPEG and MPEG) or DICOM movies can be generated of the beating or rotating vessel tree. (Multimedia
requires Data Export)
One-Touch 3D Heart VR Cath Views
These protocols provide you with 3D VR views of the heart extracted from within the chest cavity (automated
tissue and bone removal).
There are five heart VR protocols available, all launch automatically to extract the heart with no user
intervention.
All protocols are optimized for threshold, opacity, and color to best display the chambers of the heart and the
coronary vessels associated with them.
All routine 3D tools are still available in this protocol.
There are Single Phase (SP) and Multi-Phase (MP) heart VR protocols available.
Multimedia (JPEG and MPEG) or DICOM movies can be generated of the beating or rotating heart. (Multimedia
requires Data Export)
One Touch Cath Views
Positioning icons allow quick adjustment to routine patient positions used in cardiac catheterization suites.
These are oriented to Left Anterior Oblique (LAO), Right Anterior Oblique (RAO), Cranial (CRA), and Caudal (CAU)
angulations.
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Short & Long-Axis Reformats
These protocols provide you with the ability to create either SP or MP reformats in the three following planes:
Short Axis
Two Chamber Long Axis
Four Chamber Long Axis
You see a pop-up wizard when entering these protocols which helps guide the image creation in the desired plane of
the heart.
Multimedia (JPEG and MPEG) or DICOM movies of the beating heart can be generated. (Multimedia requires Data
Export).
Auto-launch to CardIQ Function from Short Axis MP is available to enhance productivity.
Automated Multi-Phase Coronary Vessel Analysis (Tracking)
There are three SP and three MP Vessel Analysis protocols available. They provide automatic vessel tracking and
curved reformat based on simple seeding.
The user is asked to place tracking points at the proximal and distal ends of the artery or arteries and the software
automatically tracks the vessel along its central axis. The protocols are optimized for left and right coronary arteries
and bypass vessels and are configurable to include/exclude any branch vessels required.
Inside the Vessel Analysis protocol you have the ability to utilize Phase Registration (discussed below).
A report can be generated and provides quantitative vessel analysis with the following feature set
Diameters
Areas
Stenosis
Multimedia or DICOM movies can be generated of the rotating vessel.
All routine 3D tools are still available when using this protocol.
Plaque density measurements in Unshifted Units (HU) can be generated.
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All images created in Vessel Analysis that are branch specific will have vessel name annotation included in the image
view port.
Phase Registration
This protocol leverages the MP post processing ability of CardIQ Analysis by helping to decrease or remove any
phase misregistration contained in 3D data sets. It accomplishes this by replacing images from one phase with those
from another at any given point along the acquisition.
Phase registration allows you to create a unique series with images from more than one phase of the R-R interval.
This new series can further be processed with any of the protocols available on the workstation.
Phase registration is also available within MP Vessel Analysis to help improve image quality (IQ) in arteries where
phase misregistration is visible.
Navigator "Fly-Through" Views
"Virtual Vesseloscopy" is available to provide an internal view of the vessel lumen.
This Navigator view can be locked to the central axis of the lumen within Vessel Analysis.
The rendering mode can be set to VR or Shaded Surface Display (SSD).
This protocol provides an intraluminal view to evaluate these conditions among others:
Stenosis
Aneurysm
Calcified plaques
Vessel narrowing
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CARDIQ FUNCTION
CardIQ Function provides quantitative analysis of the functional parameters of the left and/or right ventricle.
NOTE: Upon delivery, in addition to your CardIQ Function software, you will find an Operator Manual and a Quickstep
User Guide. This guide is a pictorial step-by-step booklet to help you work through all of the protocol options
within CardIQ Function.
In order to begin CardIQ Function with the LightSpeed system generate multiphase images from 5 95% in 10%
increments. This will provide images throughout the entire R-R interval.
Then, send this multiphase series to the workstation and launch the Short Axis MP protocol in CardIQ Analysis.
CardIQ Function can be launched from the end of the Short Axis protocol.
In CardIQ Analysis, automated contours of the left ventricular endocardium and epicardium are generated from this
MP short axis series.
Analysis is provided in both graph and "Bulls Eye" format and an HTML report can be generated which includes
statistical tables and graphical objects.
Measurements include
End Diastolic (ED) Volume
End Systolic (ES) Volume
Stroke Volume
Ejection Fraction
Peak Ejection Rate
Time to Peak Ejection Rate
Peak Filling Rates
Myocardial Wall
Mass
Thickness
Motion
Thickening
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Time Thickness
Short Axis anatomy points for CardIQ Functional Analysis are shown in the diagram below.
TERMS AND DEFINITIONS FOR CARDIAC FUNCTIONAL ANALYSIS
End-diastolic Volume (EDV)
The volume of blood in the chamber at the end of the diastolic phase, when the chamber is at its fullest (most blood
in the ventricle)
LV normal = 150 ml
RV normal = 165 ml
End-systolic volume (ESV)
The volume of blood in the chamber at the end of the systolic phase, when the chamber contains the smallest (least
amount of blood in the ventricle)
LV normal = 75 ml
RV normal = 83 ml
Stroke Volume (SV)
The amount of blood ejected from the left ventricle during systole.
LV normal = less than 80 ml
SV = EDV ESV
Units are liters/beat
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Ejection Fraction (EF)
The percentage of the blood pumped out of the left ventricle with each heartbeat, used as an indicator of overall
cardiac function
LV normal = 50 65%
RV normal = 45 60% or 10% less than LV value
EF = (SV/EDV) x 100
Myocardial Mass (Mass)
Volume of myocardium x specific density of myocardium (1.05 g/cm2)
Myocardial Mass = (105 g/cm2) x volume of myocardium
Units are in grams
Wall Thickening (WT%)
The wall thickening value identifies the same sample of myocardium in the ED and ES phases of the cardiac cycle
and compares its respective wall thickness values. It is the percentage increase in regional wall thickness from ED to
ES.
Wall Motion
The amount of movement from end systole to end diastole, measured in millimeters
Wall motion terminology
Hyperkinetic: excessive motion; a hyper dynamic heart
Hypokinetic: very little motion
Akinetic: no motion
Dyskinetic: uncoordinated or paradoxical motion
Wall Thickness (WT)
Thickness of the myocardial muscle for the specified chamber as measured from the endocardium to the
epicardium
Measured in mm
Used to detect abnormal growth of the heart
Average left ventricle wall = 10 ml
Average right ventricle wall = 3 ml
Wall Time Thickness
Regional change of wall thickness over the cardiac cycle. Multiple curves are shown corresponding to the defined
segments.
Cardiac Output (CO)
The volume of blood pumped by the left ventricle in one minute.
CO = SV x heart rate (BPM)
Units are liters/minute
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Peak Filling Rate (PFR)
The maximum increase of blood in the left ventricle (LV Volume) per unit time
Peak Ejection Rate (PER)
The maximum decrease of blood in the left ventricle (LV Volume) per unit time
Time to Peak Filling Rate (TPFR)
Time offset from the moment of end systole
Time to Peak Ejection Rate (TPER)
Time offset of the moment of peak ejection rate to the R wave of the ECG
Report Template Options
There are multiple templates available for Graphic (HTML) report creation. The fields listed are auto-populated by
each template regardless of whether information is supplied or not. Any additional graphs/bulls-eye plots you have
selected to be added to the report will also populate, regardless of template chosen. An example of one of the
templates is listed below.
base.tpl
Patient Information
Study Comments
LV Volume Results
RV Volume Results
LV Volume Graph
RV Volume Graph
Four x Bull's Eye Plots
Wall Thickness ED
Wall Thickness ES
Wall Motion
Wall Thickening
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OUTPUT GRAPHICS AND CONTOURS NEEDED
There are multiple contouring options within the CardIQ Function package. Please see below the output options
available pertaining to the contours that have been drawn.
Contours Drawn:
Endocardial contour of the ED and ES Phases only
Contours Drawn
Endocardial contour of the ED and ES Phases only
Reference point placement across the study
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Contours Drawn
Endocardial contour of the ED and ES Phases only
Epicardial contour of the ED and ES Phases only
Reference point placement across the study
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Contours Drawn
Endocardial contour of all phases
Epicardial contour of all phases
Reference point placement across the study
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APPENDIX A: ACRONYMS
3D Three-dimensional
Ao Referring to the aorta
BPM Beats per minute
CAD Coronary artery disease
CAU Caudal
CRA Cranial
CS Coronary sinus
CT Computed tomography
Cx Circumflex coronary artery (also referred to as the "Circ")
ECG Electrocardiograph
ED End diastolic
EF Ejection fraction
ES End systolic
HDL High-density lipoprotein
HTML Hypertext Markup Language
HU Hounsfield unit
IQ Image quality
LA Left atrium
LAD Left anterior descending coronary artery
LAO Left anterior oblique
LDL Low-density lipoprotein
LMA Left main artery
LV Left ventricle
MIROI Multiple image region of interest
MP Multiple phase
MV Mitral valve
PA Pulmonary artery
PDA Posterior descending coronary artery
RA Right atrium
RAO Right anterior oblique
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RC Right coronary artery
ROI Region of interest
RV Right ventricle
Sec Second (time)
SP Single phase
TV Tricuspid valve
VR Volume rendering