Clinical Radiology (2005) 60, 939952

REVIEW

Multi-detector row computed tomography: imaging the coronary arteries

N.E. Manghata,*, G.J. Morgan-Hughesb, A.J. Marshallb, C.A. Roobottoma
Departments of aClinical Radiology, and bCardiology, Derriford Hospital, Plymouth, UK
Received 2 December 2004; received in revised form 7 April 2005; accepted 4 May 2005

KEYWORDS
Coronary artery; Multi-detector computed tomography; CT; Review

Over the last 2 years, multi-detector row computed tomographic (MDCT) cardiac imaging has continued to rapidly develop and evolve from the experimental research setting to become a useful clinical tool. The increasing availability of MDCT presents todays clinicians with an additional non-invasive diagnostic cardiac imaging method, in particular for the coronary arteries. With the advent and increasing clinical use of 16-detector row machines, and now with the imminent clinical emergence of 64-channel machines, the improvements in spatial and temporal resolution and sophisticated ECG-gating are allowing motionfree, fast, accurate, detailed, contrast-enhanced cardiac imaging that begins to approach the accuracy of traditional invasive diagnostic techniques. Additional diagnostic information may also be provided. Q 2005 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Introduction
Coronary artery disease continues to be one of the leading causes of morbidity and mortality in England and Wales; 108,000 deaths from coronary disease were recorded in the year 2000. More than 41,000 of these deaths took place under the age of 75 years. The current prevalence of angina is over 2 million in the UK,1 about 300,000 people experience a myocardial infarction each year and coronary disease accounts for about 3% of all hospital admissions in England.2 Following other non-invasive diagnostic procedures, such as exercise-ECG testing, conventional invasive catheter coronary angiography currently provides the standard of reference for denitive diagnosis. 35 Its advantages are high spatial (w0.15 mm) and temporal resolution and the options of performing percutaneous angioplasty or
* Guarantor and correspondent: N.E. Manghat, Department of Clinical Radiology, Derriford Hospital, Plymouth PL6 8DH, UK. Tel.: C44 1752 792186; fax: C44 1752 792185. E-mail address: docnatman@msn.com (N.E. Manghat).

stent insertion on the same occasion. However, many of these examinations do not lead to revascularization therapy; up to 25% of subjects in the UK are found to have normal coronary arteries,6 and 66% of subjects in the USA3 undergo invasive angiography for the presence and assessment of disease severity alone. In order to prevent unnecessary invasive tests, a reliable and reproducible non-invasive diagnostic test for the detection and grading of coronary artery stenosis is highly desirable. The most promising method at present is multi-detector row computed tomographic (MDCT) coronary angiography.79 Imaging the coronary arteries is a technical challenge, owing to continuous cardiac motion and the small luminal diameter of the vessels. High-performance temporal resolution (time needed to acquire one image) and spatial resolution (ability to distinguish between adjacent structures) is therefore required. There have been recent technical advances which have led to improvements in temporal resolution, fast ECG-gated scanning10 and reconstruction techniques for motion-free cardiac imaging, with improvements in spatial

0009-9260/$ - see front matter Q 2005 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.crad.2005.05.006

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resolution for sub-millimetre imaging and reduction in radiation exposure times, resulting in the generation of images without artefacts. Cardiac imaging with MDCT acquired with a single breath hold confers additional benets, providing information about cardiac morphology, volume assessment and ejection fraction.11,12 MDCT cardiac perfusion application software is under ongoing development for potential use in the clinical setting.13,14 The ultimate aim of MDCT coronary angiography will be to complement conventional diagnostic invasive coronary angiography15,16 and other existing imaging methods, avoiding negative invasive coronary angiograms and assisting the planning of any revascularization procedure. MRI also can assess cardiac morphology, function, perfusion and viability with low temporal resolutions (20 to 50 ms). However, the 3D spatial resolution achievable is marginal for coronary arterial imaging and is therefore not yet reliable, thus limiting this particular application.17 We present this update review of cardiac MDCT, with particular emphasis on coronary artery imaging. Brief historical perspectives and present and future uses are discussed with reference to current clinical experience in our own institution.

supercial erosions. Resultant adherent luminal plaques may be lipid-rich, brous or calcied.20,21 Advanced disease consists of multiple stenotic lesions of varying degrees of severity, leading to a chronic or acute reduction in coronary perfusion. It is now realized that the accumulation of atherosclerotic plaque in the coronary arteries begins much earlier than the development of luminal narrowing, with acute coronary syndromes often precipitated by the sudden rupture of a previously non-signicantly stenosed plaque.20 Early atherosclerotic plaque accumulation is associated with compensatory vessel expansion, also known as positive arterial remodelling; therefore, estimation of luminal diameter alone is insufcient.21 Assessment of these early changes is an important aim when faced with preventing the progression and complications of coronary artery disease.

Overview of cardiac CT evolution

Coronary arterial CT imaging has been a challenging area of research because of limitations in scanner speed, volume coverage and temporal resolution (Table 1). Even higher isotropic spatial resolution is now possible with the next generation of CT technology, i.e. the 32-channel and 64-channel MDCT (0.35 mm collimation and 340 ms rotation times). The 64MDCT is currently being developed, with recent results indicating visual clarity of up to fth-order coronary arterial branches.22 This should reduce scan times. In particular, the ability to acquire a complete sub-millimetre coronary angiogram within w5 s, compared with 20 s for the 16-detector row scanner, renders imaging less susceptible to cardiac dysrhythmias and reduces beat-to-beat variability. The clinical impact of this new CT technology, particularly for cardiac applications, remains to be studied. It would seem to represent the future of coronary computed tomographic angiography (CTA) and will be the focus of future research.

Pathology of coronary artery disease

When using and interpreting cardiac MDCT coronary angiography, it is useful to have some understanding of the pathological processes involved in the development of atherosclerosis. Angina is caused by coronary artery atherosclerosis leading to luminal stenosis. A mature brolipid plaque has a core of extracellular lipid, surrounded by smooth muscle cells, and is separated from the arterial lumen by a brous cap.18,19 At the edge of the plaque is a vulnerable zone that is often the site of rupture; it is shown to have a less well-organized structure. The inherent inammatory process makes the plaque unstable, and thrombosis may occur on a plaque ssure or on
Table 1 Evolution of cardiac CT.

1972: CT was rst introduced 1981: Cardiac imaging rst reported on single-detector row spiral CT scanner. Motion-free images not achieved58 1982: Electron-beam computed tomography created for cardiac imaging.58 Motion artefacts persisted.58 Mainstay application coronary calcium scoring58 1998: Four-detector row CT allowed eightfold increase in performance over single detector row CT. Coronary angiography sometimes diagnostic but not reliable for clinical use (Fig. 1(a))58 2002: 16-detector row CT introduced (gantry rotation times 400500 ms; collimation 0.6250.75 mm; near-isotropic resolution 0.5! 0.5!0.6 mm). CT coronary angiography clinically useful (Fig. 1(b)).

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Technical and practical aspects of cardiac CT

A number of factors must be optimized in order to achieve the highest quality images.

Spatial resolution
Patient position in the scanner is vitally important since, if the subject is placed off-centre, images with suboptimal resolution are generated. The coronary arteries are of small luminal diameter, from 4 to 5 mm in the left main stem to 1 mm in the distal left anterior descending artery. Sub-millimetre spatial resolution is necessary in both the axial and the longitudinal planes, with isotropic imaging (in all planes) being the ideal, to delineate small sub-millimetre coronary arterial branches. It is considered that for differentiation of a 10% to 20% arterial stenosis, 0.3 mm isotropic spatial resolution is needed.23

Temporal resolution
The coronary arterial tree must be imaged during continuous complex cardiac motion and variable patient heart rates. Reducing motion artefacts requires image acquisition during a phase of the cardiac cycle when the heart is relatively stationary; this period is typically in late diastole, about 75% to 85% of the RR interval on the ECG. In combination with high spatial resolution, image acquisition should cover the whole heart in a single breath hold. Positioning the heart near the centre of rotation of the gantry ensures that the temporal resolution of all cardiac elements remains constant, rather than showing a gradual improvement as the gantry rotates.24 Temporal resolutions are limited by the system gantry rotation times, which should be as fast as possible; however, mechanical forces limit rotation itself, with a realistic limit being 50 to 200 ms.25 Ideally, a temporal resolution of !50 ms is needed for all coronary CTA to cover all heart rates, but methods for working with a lesser temporal resolution may be followed. The use of beta-blockade in lowering the heart rate prolongs the diastolic phase,26 allowing increased imaging time. Furthermore, with new alternative complex reconstruction algorithms, temporal resolution of 65 ms is achievable with motion-free imaging up to 100 bpm. This is still inferior to conventional angiography under screening (!10 ms).

Figure 1 (a) Coronal CT angiography using 4-slice technology showing a lesion in the proximal left anterior descending artery. (b) CT angiography using 16-slice technology showing vessel clarity in the coronal plane.

ECG-gating
Cardiac motion artefact caused by pulsation and rotational movement may be minimized, with concurrent high spatial resolution, if the scanned volume of data is reconstructed at time points when cardiac motion is least; this occurs during diastole (Fig. 2(a) and (b)). Heart-phase data are acquired with reference to the simultaneously acquired electrocardiographic trace. MDCT is prospectively triggered, or gated, when sequential imaging is performed, and retrospectively gated during continuous spiral imaging. Essentially, during prospective gating, the scan is triggered at a dened position along the R wave to

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Figure 3 The upper ECG trace demonstrates the RR interval; the middle trace shows prospective gating where scanning and reconstruction windows are the same; the lower trace shows retrospective gating where scanning is continuous and the reconstruction window can be set anywhere along the RR phase of the cardiac cycle.

Figure 2 ECG-gating. (a) Axial cardiac CT in systole exhibiting motion artefact. (b) Axial cardiac CT in diastole showing improved image quality.

R wave interval (RR interval; the R wave represents the phase of ventricular depolarization) along the ECG during consecutive heart beats. This is usually during late diastole, which is the method traditionally used by EBCT.27 The examination time is thus related to overall heart rate. Prospective imaging is heavily dependent on a regular heart rate, and artefact and misregistration of data occur in the presence of cardiac arrhythmias. Retrospective gating allows for greater

exibility. This method acquires phase data continuously throughout the cardiac cycle and necessitates multi-detector scanning, allowing images to be viewed at any point along the RR interval (Fig. 3).28 Most MDCT scan protocols have a xed overlapping spiral pitch of 0.25 to 0.375. If the pitch is too high (table-feed too rapid) for a given heart rate, this will result in data insufciency in the reconstructed image, since every position of the heart must be covered by a detector row at all points during the cardiac cycle. The pitch can now be automated to allow for any variations in heart rate. The resulting overlapping image sections enable nearly isotropic image data sets of the entire cardiac volume. Retrospective ECG-gating is thus the method of choice for contrast-enhanced images of the coronary arteries in high spatial resolution.

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With retrospective gating, the temporal resolution can be further improved by using portions of data from more than one consecutive cardiac cycle, to reconstruct a single image from a particular phase. This is termed partial sub-segmental reconstruction, and can be set according to the patients heart rate at the time of scanning, determining the number of cardiac cycles that will be sampled to produce that one image in any phase along the RR interval. These algorithms, however, are sensitive to changing heart rates or beat-tobeat variation and this can lead to step artefact (Fig. 4(a) and (b)).29 Imaging in late diastole or w75% of the RR interval is the phase of least cardiac motion for the majority of coronary artery segments (Fig. 5(a) and (b)). Individual patients may have portions of cardiac anatomy with motion patterns that do not conform to this, requiring analysis at different phases.30 The motion of the left main stem, left anterior descending (LAD) and circumex arteries follow the motion of the left ventricle; the right coronary artery (RCA) motion is related to right atrial and ventricular contraction, which is not minimal in end-diastole (Fig. 5(c)). The duration of the diastolic phase with minimal cardiac motion is directly related to the heart rate. Most studies suggest that heart rate is inversely proportional to image quality on CT coronary angiography.31,32 At higher heart rates good quality imaging is achievable, but this is less reproducible. Therefore slower heart rates are preferred, in order to achieve consistently high-quality coronary arterial imaging. In the absence of contraindications, either beta-blockade is administered orally, 1 h before scanning, or short-acting intravenous (IV) beta-blockade (e.g. metoprolol, 2.5 to 20 mg) is administered shortly before scanning and titrated to an optimum heart rate18 of w55 to 65 bpm.

Timing and delivery of intravenous contrast agent

Imaging without contrast is used for coronary artery calcium scoring. Differentiation of coronary vessel lumen from surrounding soft tissue necessitates the use of an IV contrast agent. With the introduction of increasingly fast acquisition techniques, careful optimization of contrast medium delivery methods is needed to ensure consistent, homogeneous enhancement of the coronary arterial tree. This optimum level of contrast should allow distinction of intraluminal lesions without obscuration of calcied arterial lesions. Delivery timing of contrast medium into the

Figure 4 (a) Marked step artefact is seen in this multiplanar reformation of the right coronary artery when using the Segment (GE Medical Systems) algorithm (data from one cardiac cycle). (b) Image review using the Burst Plus (GE Medical Systems) algorithm (data from four cardiac cycles) markedly improved image quality.

coronary arterial tree can be assessed by rst performing a test bolus scan, which generates a graph of contrast intensity versus time from initiation of the IV contrast injection; this timing may then optimally trigger scanning during MDCT coronary angiography. Alternatively, an automated contrast bolus-tracker technique33 can be followed. Timing will clearly depend upon the IV cannula position and size, the rate of injection and the

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Figure 5 (a) 3D volume-rendered (VR) image of the left coronary circulation seen in systole. (b) The same image reviewed in late diastole with greatly improved vessel clarity; it is useful to review the quality of this 3D VR image rst, before choosing the optimal phase to analyze the multiplanar data. (c) The origin of the right coronary artery is reviewed at phase 75% (top image) and 45% (bottom image).

patients cardiac output. Using 8- or 16-slice scanners, scan times range from 20 to 30 s. Following a period of hyperventilation and a single breath hold, 100 to 150 ml contrast medium is injected IV at rates of 3 to 5 ml/s, through a power injector via an antecubital vein. The scanning delay is calculated from the commencement of IV injection to the time of maximal enhancement of the ascending aorta plus an additional 3 to 5 s to allow for lling of distal coronary arteries. During actual MDCT angiography, IV injection of 100 ml iodinated contrast agent at 4 ml/s followed by a saline chaser bolus, 40 to 50 ml,34 has been recommended. This has the advantages of reduced volume and dose of IV contrast medium, optimal and consistent vascular enhancement and decreased contrast attenuation value within the superior vena cava and right heart (Fig. 2(b)) which, in turn, diminishes beam-hardening artefact that compromises visualization and evaluation of the right coronary artery.

compared with prospective ECG-gating, because of the continuous radiation exposure and overlapping data acquisition at a low table-feed. In addition, as progressively thinner beam collimations with additional detector rows are used, the dose generally will increase. Doses can be minimized by the use of automated exposure control and ECG-gated tube current reduction modulation techniques employed during phases of maximal cardiac movement, where useful information gained may be minimal and considered less important. By means of ECG-gated dose modulation techniques, tube current can be reduced by 30% to 50%, thereby aiming for exposure reductions36 from w10 mSv to 5 to 7 mSv for MDCT coronary angiography, depending upon the heart rate. This method requires a stable, steady heart rate in order that a phase reduction in exposure should not compromise diagnostic image quality (Table 2).

Radiation dose
MDCT scanners can achieve higher tube currents with improved image quality, but with increased patient radiation dose. Radiation exposures are relatively high in MDCT coronary angiography, ranging from 5 to 10 mSv,35 which is comparable with conventional coronary angiography. Typically for retrospectively gated 16-MDCT angiography, 120 kV and 340400 mAs are used. Higher radiation exposure is a factor when using retrospective

Display techniques and post-processing protocols

Sub-millimetre, high spatial-resolution coronary angiographic data are complex, with an ever increasing number of display techniques and postprocessing protocols becoming available for use on CT workstations. Many of these protocols have yet to be evaluated in terms of their accuracy in detecting and quantifying coronary arterial stenosis. The reconstruction of data from all cardiac phases within the RR interval may result in 2000 to

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Table 2

Summary of practical tips. Adequate explanation improves patient cooperation and image quality If placed off-centre, images with suboptimal spatial resolution are generated Positioning heart near centre of gantry rotation ensures that temporal resolution of all cardiac elements remains constant Lowering heart rate prolongs diastolic phase, allowing increased imaging time Administer either oral beta-blockade 1 h before scanning, or short-acting IV beta-blockade (e.g. metoprolol 2.520 mg) immediately before scanning; titrate to optimum heart rate of w5565 bpm Set reconstruction algorithm according to patients heart rate at time of scanning Retrospective ECG-gating is method of choice Reconstruction algorithm using data from two cardiac cycles often best Calcium score: Non-contrast IV cannula position: Right antecubital vein Timing: Test bolus scan; maximal enhancement of ascending aorta plus additional 3 s to allow for lling of distal coronary arteries Hyperventilation and a single breath hold 100 ml IV contrast agent at 45 ml/s, followed by 40 ml saline chaser bolus, reduces volume and dose of IV contrast agent, resulting in optimal and consistent vascular enhancement and better evaluation of the right coronary artery Review different phase images to determine optimum reconstruction with least artefact; 3D volumerendering is helpful Late diastole (75% to 85% of RR interval) is phase of least cardiac motion for most coronary artery segments 45% often best for right coronary artery Review axial data rst, then optimize use of multiplanar reformation and vessel analysis software Functional information may require more phases

Patient factors

Heart rate and rhythm

ECG-gating Contrast delivery

Post-processing

3000 individual transaxial images. The analysis, interpretation and documentation of these data are time consuming and not yet standardized, and therefore will be the subject of ongoing research. Nonetheless, evaluation of angiographic data and the presence or absence of atherosclerotic disease is often best performed initially using the axial data,37 once the analytically optimal cardiac phases with the least cardiac motion have been identied. However, given the inherent tortuosity and variability of coronary arterial anatomy, evaluation of axial data alone is often insufcient. A number of semi-automated, interactive post-processing display protocols may be followed to facilitate a more accurate appreciation of the entire complex 3D anatomy, or simply to display certain regions of interest. Multiplanar reformation (MPR) and maximumintensity projection (MIP) in 2D are useful secondline tools. The isotropic or virtually isotropic imaging allows data to be rearranged in any standard cardiological or arbitrary imaging plane with the same quality as the original axial data. There is also the option of creating a curved-vessel MPR where, by plotting the course of a vessel using the axial data set, an image plane is automatically created using the vessel as its axis and delineating it in its entirety (Fig. 6). These algorithms also allow the depiction of a curved vessel as a linear conformation. The image may be rotated 3608 along its axis, thus assisting the illustration of

both circumferential and eccentric stenotic plaques, and allows quantication of any stenosis. Again, although its usefulness can be appreciated, this type of analytical software must be researched to assess its accuracy. Post-processing software in 3D, commonly by 3D volume rendering (VR) or via cardiac cine/movie loops, can make complex data display more intuitive and sometimes quite dramatic (Figs. 5(b), 12 and 13). These methods have been augmented by the use of other more experimental algorithms, whereby entire courses can be grown by tracking a contrast-enhanced vessel (Fig. 7(a)) or by permitting the alteration of contrast enhancement density of any or all of the left and right chambers, outow tracts and myocardium (Fig. 7(b)).

Clinical applications of cardiac CT

The usefulness of cardiac CT is under continual evolution from research to clinical setting. Ultimately, the aim is to establish MDCT as a complementary adjunct to conventional established techniques.

The calcium score

CT reliably detects arterial calcication and allows quantication. Importantly, the presence of

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Figure 6 Curved multiplanar reformation (MPR) depicts the right coronary artery (RCA) in its entirety (upper image). Another image of the RCA using curved MPR shows soft and calcied plaque contributing to a signicant stenosis (middle image); an eccentric, calcied lesion with a brous cap (arrow) is depicted with the vessel in a linear conformation (bottom image).

Figure 7 (a) Contrast-enhanced vessels have been grown to depict the normal left and right coronary circulation (top image), and rotated to demonstrate the origins of both vessels from their respective coronary sinuses (bottom image); surface calcication can also be seen. (b) Normal coronary anatomy is shown with reference to the left and right chambers by altering contrast-enhancement densities of the chambers and the myocardium.

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image is the product of its area multiplied by a cofactor indicating the maximal attenuation (density) within the lesion. Volumetric and absolute mass quantication algorithms are also available, demonstrating increased accuracy, consistency and reproducibility, which may replace the traditional methods of scoring.47 However, these scores have not been validated in large cohorts.

Clinical signicance
The specicity of coronary calcium loading or volume detected by CT, to assess the presence, extent and haemodynamic signicance of underlying stenoses, is only moderate.42 The ACC/AHA have summarized the role of CT calcium scoring.49 Essentially, a negative CT indicates that the presence of atherosclerotic plaque, including unstable plaque, is very unlikely. A positive CT conrms the presence of a coronary atherosclerotic plaque. The greater the amount of calcium, the greater the likelihood of occlusive coronary artery disease; however, there is not a one-to-one relationship and the overall true plaque burden is underestimated. Large prospective, populationbased, cohort trials are currently underway to assess the prognostic value and risk stratication of calcium scoring.43,44

Figure 8 A heavily calcied left main stem and proximal left anterior descending coronary artery.

calcium within the coronary arteries almost always signies atherosclerosis (Fig. 8) and generally a more advanced stage of arterial remodelling.23,58 Coronary calcium load has been found to progress over time, increasing by 15% to 25% per year without treatment; studies report that the rate of progression may either slow or stop with lipidlowering therapy.38,39

Diagnostic MDCT coronary angiography

The acquisition methods have been described. It is important to understand the diagnostic accuracy of this technique when compared with the reference standard of invasive catheter angiography. A number of crucial observations have been drawn from 4-slice CT coronary angiography trials. The assessability and accuracy of this method for detection of signicant coronary artery stenoses has been found too low to be included in routine clinical practice45,46 without the induction of profound bradycardias, and coronary artery calcication and motion artefact have caused difculties in vessel visualization. Between late 2002 and early 2003, the results of two studies, involving 136 patients undergoing multi-slice CT coronary angiography with 16-slice CT, were published.15,16 There are a number of similarities between these studies. All the patients involved were pre-treated with beta-blockers. The mean heart rate of these patients was between 56 to 62 bpm. Both studies used the Siemens Sensation 16 (Siemens Medical Solutions, Forchheim, Germany). Detector collimation in both cases was

Detection
Calcium has a high attenuation coefcient; a threshold of 90 or 130 HU is therefore usually applied. A typical protocol for 16-MDCT involves 1.25-mm collimation, 20-mm table-feed between each acquisition, reconstruction of 8 images at 2.5mm thickness per table location, 0.4- to 0.5-s gantry rotation, scanning from the carina to the cardiac apex and using prospective gating at w75% phase of the RR interval. A tube voltage of 120 kV and w80 mA provides sufcient signal-to-noise ratio to detect small calcied lesions. Whereas optimal image quality is obtained with retrospective gating, it is at the expense of higher radiation exposure.40 Calcium load is determined semi-automatically with post-processing algorithms. The Agatston calcium score28 is the most widely employed semiquantitative method in EBCT. Modied versions of this score are used in MDCT, i.e. the Agatston score equivalent,41 which is the sum of all calcium clusters scores. The score of each lesion on each

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0.75 mm with gantry rotation of 0.42 s. The studies used a solitary-phase contrast medium injection and no saline ush. The multislice CT coronary angiograms were evaluated (all major coronary arteries and side branches) and compared with invasive studies by blinded investigators. The attempted analysis of all coronary arteries and branches, rather than only selected proximal or mid-vessel segments, represented a major advance on the 4-slice CT coronary angiography trials. The scans were predominantly evaluated using established techniques involving analysis of axial data and MPR and MIP reconstructions. Nieman et al. did not exclude any coronary arteries from multislice CT analysis, in their comparison with invasive coronary angiograms. Reported sensitivity and specicity for the accurate detection of R50% diameter reduction in stenoses were 95% and 86%, respectively. The somewhat lower specicity resulted from a total of 20 coronary arteries that were assessed false positively. These false-positives were almost universally due to vessel calcication. Ropers et al. did exclude unevaluable coronary arteries, but these only amounted to 12% (again this compares favourably with the majority of previous studies). Following the exclusion of these arteries, these authors reported a sensitivity of 92% and a specicity of 93% for the accurate detection of R50% reduction in lumen diameter in all coronary arteries and branches with a diameter of R1.5 mm. In comparison with invasive angiography, multislice CT correctly classied 85% of the patients who had signicant coronary artery disease. In 2004, further studies4749 using 16-detector CT also demonstrated high sensitivity and specicity (Table 3). Morgan-Hughes et al.50 assessed the accuracy of 16-slice acquisition MDCTA on an AHA segment-by-segment basis rather than on a pervessel basis for O50% stenoses. Using partial subsegmental reconstruction algorithms, they reported
Table 3 Study Summary of coronary MDCT study data. Sensitivity Specicity (%) (%) Negative predictive value (%) 97 97 98 98 99.8 99

Figure 9 A signicant calcied stenosis in the proximal left anterior descending coronary artery with comparative invasive imaging.

Nieman et al.15 Ropers et al.16 Mollet et al.47 Martuscelli et al.49 Kuettner et al.48,a Morgan-Hughes et al.50,b
a b

95 92 92 89 98 89

86 93 95 98 98 98

Agatston score equivalent (ASE) !1000. ASE !400.

sensitivity, specicity, and positive and negative predictive values of 83%, 97%, 80% and 97%, respectively. Repeat analysis excluded the subgroup of patients with a signicant coronary artery calcium score (O400), and found sensitivity, specicity, and positive and negative predictive values of 89%, 98%, 79% and 99%, respectively (Fig. 9). The ability to visualize sub-millimetre branches of the coronary arterial tree with 16-MDCT also allowed the reliable visualization and assessment of grafts and stent patency. Kuettner et al. restricted analysis of patients with ASE !1000, and sensitivities and specicities increased from 72% and 97%, to 98% and 98%, respectively.48 Experience, even with 16-slice CT, repeatedly points to the detrimental effect of coronary artery calcication on visualization, and to how correct evaluation of the coronary artery lumen, because of partial volume averaging, leads to an overestimation of the degree of stenosis and thus a falsepositive result. Study exclusion criteria of increased heart rate, arrhythmias and less than full evaluability of the coronary arteries must still be considered limitations of the method. The technique has, however, reached an acceptable level of diagnostic accuracy and its precise role in cardiovascular medicine needs to be elucidated. High specicity and negative predictive value are constant features of 16-MDCT coronary angiography, and this may allow the avoidance of a rst-time invasive

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diagnostic coronary angiogram in a select patient group, and also the potential of reliably excluding severe coronary disease in individuals at low to intermediate risk with uncertain clinical ndings and presentation. Perhaps those patients who have refused catheter angiography, those for whom catheter angiography has proved unsuccessful and those for whom the invasive procedure carries particular increased risk, should also be considered for MDCT coronary angiography. As the volume of cardiac MDCT research continues to grow, so does the need for long-term, prospective studies to investigate hard end-points or future clinical events, particularly for those patients who have had a previously negative CT coronary angiogram.

Atherosclerotic plaque characterization

CT angiography has the advantage of demonstrating the vessel-wall atherosclerotic plaque, in addition to enabling assessment of luminal patency (Fig. 10). The assessment of plaque size and composition may have signicant clinical implications. Because of arterial remodelling, plaque progression is not generally reected in luminal dimensions. Noncalcied plaque may be more unstable and prone to acute rupture leading to acute myocardial infarction or acute coronary syndrome, whereas calcied plaque is associated with plaque stability. However, the morphological characteristics of these vulnerable plaques are incompletely understood. MDCT may help identify and characterize non-calcied plaques.51 Intravascular ultrasound (IVUS) is an invasive and expensive way to characterize plaque. MDCT plaque

appearances were compared with IVUS features and characterized by mean attenuation values: Soft plaque, 14 HU (G26); intermediate plaque, 91 HU (G21); and calcied plaque, 419 HU (G194). However, there is some overlap, particularly between predominantly lipid-containing lesions and brous coronary lesions. Thus the identication of total plaque burden, which would include vulnerable plaque, could provide a superior indicator for coronary risk assessment. On the other hand, the identication and prediction of rupture of a single culprit plaque may not be a realistic notion. The debate arises as to whether MDCT should be used as a screening and monitoring tool. Monitoring the effectiveness of lipid-lowering therapy with respect to the calcium score may also be a potential low-dose CT tool, but what should be the clinical decision when a potentially vulnerable, non-signicantly stenotic plaque is identied in an otherwise asymptomatic individual?

Other clinical uses and future considerations

Coronary artery anomalies are being described with greater frequency because of the increased use of coronary angiography. Myocardial bridging and ectopic aortic origins of the coronary arteries are generally asymptomatic, unless the course is

Figure 10 Vessel-wall atherosclerotic plaque can be characterized in addition to luminal diameter; soft and calcied plaque is seen here in the left anterior descending coronary artery.

Figure 11 The right coronary artery arises from the left coronary sinus in this individual, taking a course between the aorta and right ventricular outow tract (arrow), where impingement may cause ischaemic symptoms.

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altered to pass between the aorta and the right ventricular outow tract (Fig. 11) or via a prolonged intramuscular course, both of which may result in vessel impingement and ischaemic symptoms. Anomalous coronary arterial origins from the pulmonary artery and also congenital coronary arteriovenous stulae usually become symptomatic during infancy and childhood. Conventional angiography may not always delineate the potentially complex anatomy in full, but this can be achieved with MDCT coronary angiography,52 in particular by means of advanced postprocessing techniques (Fig. 12).53 Using these same techniques, bypass grafts54,55 (Fig. 13) and intracoronary stents can be assessed for luminal patency56,57 (Fig. 14). Increasing information with respect to plaque composition on MDCT has enabled the display of calcied or potentially vulnerable plaque on navigational or y-through virtual coronoscopy which, although quite dramatic, is currently of questionable clinical use. Although myocardial perfusion defects have been demonstrated on

non-ECG-gated contrast-enhanced CT for many years, global volumetric myocardial perfusion assessment is still experimental. Even the temporal resolution of 16-MDCT angiography may be insufcient and deferred for the 64-detector research setting, which may perhaps enable the simultaneous evaluation of coronary stenoses, occlusions and their haemodynamic signicance. The role of cardiac MDCT angiography is also yet to be fully evaluated in the emergency setting within the clinical context of acute myocardial infarction58 or acute coronary syndromes. This diagnostic method may allow the streamlining of diagnostic decision-making upon presentation.

Figure 12 Circumex artery stula. This posterior view shows a grossly dilated circumex artery which stulates with the coronary sinus (arrow), which itself is markedly dilated.

Figure 13 A patent left internal mammary artery graft to the left anterior descending artery is shown by 64MDCT imaging technology (3D volume-rendered image); note the surgical clips.

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clinical applications of cardiac CT. Thanks are also due to General Electric Medical Systems for assistance. Figs. 13 and 14 are used by kind permission of D. Foley. Particular thanks are extended to all the CT radiographers at Derriford Hospital for their continued enthusiasm and support.

References
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Figure 14 Luminal evaluation of this intracoronary stent in the left anterior descending coronary artery is achieved by 64-MDCT curved multiplanar reformation.

Conclusion
With the advent and increasing clinical use of 16detector row machines, and now with the imminent clinical emergence of 64-channel and at-plate technology, the improvements in spatial and temporal resolution, sophisticated ECG-gating and post-processing software algorithms are allowing motion-free, fast, accurate, detailed, contrast-enhanced cardiac imaging that not only rivals the accuracy of traditional invasive and non-invasive diagnostic techniques, but also provides additional diagnostic information in a single study. The number of unevaluable studies is decreasing. It must still be remembered that not all cases can be studied reliably; cardiac dysrhythmias, tachycardias and severe calcication decrease the accuracy of the results. MDCT coronary angiography may soon obviate the need for diagnostic catheter angiography altogether in select cases, and may become routine in the assessment of individuals at low to moderate risk. It would not seem advisable to image those at high risk of signicant stenosis, since it is this group that may require immediate intervention. However, we need to determine exactly when MDCT should be deployed for optimum clinical and costeffective benet. MDCT should become an imaging method complementary to MRI and conventional invasive catheter angiography. The huge evolutionary potential of MDCT cardiac imaging is yet to be fully realized, but the prospects are exciting.

Acknowledgements
The Royal College of Radiologists Research Fellowship Award 2004/5 funds N. Manghat to study the

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