CTA OF THE EXTRACORONARY HEART

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1 CTA OF THE EXTRACORONARY HEART Charles White MD Director of Thoracic Imaging Department of Radiology University of Maryland NO DISCLOSURES

2 CARDIAC CASE DISTRIBUTION Coronary CTA 30% ED chest pain 10% Post-CABG -10% Other 50%» Congenital HD» Valves» Pulmonary Veins RF ablation» Tumor» Perfusion, dysplasia

3 CARDIAC CT Outline Technical Aspects Extra-coronary cardiac CT» Chambers» Valves» Masses» Congenital Function and perfusion Interactive Workstation

4 TECHNICAL ASPECTS CORONARY vs EXTRACORONARY CTA CONSIDERATIONS TYPE OF ECG-GATING CONTRAST INJECTION LENGTH OF SCAN

5 CLASSIC ECG-GATING IN MDCT Prospective part of cardiac cycle Lower radiation HR sensitive (<65bpm) Ca Scoring Retrospective entire cardiac cycle Higher radiation less sensitive to HR Coronary CTA Tube output ON Tube output OFF Tube output (x-ray) ON Spiral Acquisition

6 RETROSPECTIVE GATING DOSE MODULATION Retrospective ECG Tagging Tube output (x-ray) ON Spiral Acquisition Retrospective ECG Tagging With Dose Modulation Maximum tube output (100%) Reduced tube output (20%) Spiral Acquisition

7 ECG-GATING IN MDCT CORONARY VS EXTRCORONARY CTA Coronary CTA Prospective is preferred Retrospective if:» High or irregular heart rate» Large BMI» Need functional info Extracoronary CTA Indications often require function Retrospective more often used If prospective used, looser HR/BMI limitations 2º less strict IQ needs

8 TECHNICAL ASPECTS CONTRAST ADMINISTATION CARDIAC CTA (Majority) Test injection» 20 6 cc/sec Injection protocol» 80 ml 6 cc/sec» 40 ml 5 cc/sec» 50 ml 5 cc/sec Bolus tracking 100 CC CARDIAC CT (R sided) Test injection» 20 6 cc/sec Injection protocol» 80 ml 6 cc/sec» 50 ml 2 cc/sec» 50 ml 5 cc/sec Bolus tracking 130 CC Courtesy: MedRad

9 CONTRAST ADMINISTATION CARDIAC CTA (Majority) CARDIAC CT (R sided)

10 LENGTH OF SCAN

11 ITERATIVE RECONSTRUCTION (225 LB.) FBP Iterative Recon

12 SPECIFIC DISEASE OUTLINE Chambers Valves Masses Congenital LV analysis (function, perfusion)

13 CHAMBERS CARDIAC VIEWS 4CH Axial 2CH VLA 2CH SA

14 LEFT ATRIAL EVALUATION Treatment for Atrial Fibrillation Radiofrequency ablation Probing tool destroys abnormal conduction pathways in LA Risk of post-procedure pulmonary vein stenosis

15 LEFT ATRIAL EVALUATION

16 LEFT ATRIAL EVALUATION

17 LEFT ATRIAL EVALUATION NORMAL VARIANT

18 LEFT ATRIAL EVALUATION-COMPLICATION

19 LEFT ATRIAL EVALUATION - STENOSIS 18 (5%) of 335 pts developed pulmonary vein stenosis post RF ablation for AF From: Saad Ann Int Med, 2003

20 LA RF ABLATION COMPLICATION ATRIOESOPHAGEAL FISTULA Courtesy: S. Aquino MD

21 LA THROMBUS

22 LV ANEURYSM

23 PSEUDOANEURYSM

24

25 CARDIAC VALVES

26 AORTIC VALVE ASSESSMENT

27 CALCIFIED AORTIC VALVE

28 BICUSPID AORTIC VALVE 1-2% of population M:F = 2:1 Predisposition to AS, usually in middle age Assoc with coarctation, William s Sx

29 VALVES IN MOTION Normal Stenotic-bicuspid

30 AORTIC STENOSIS Planimetric measurements of AVA with retrospectively electrocardiographically gated 16-detector row CT allow classification of AS that is similar to that achieved with measurements by using echocardiographic methods Alkahdi H. Radiology. 2006;240:47-55.

31 AORTIC REGURGITATION

32 AORTIC REGURGITATION

33 AORTIC REGURGITATION Results of assessment of AR with 64- section CT are similar to those with TTE. Alkadhi H. Radiology. 2007;245:111

34 SUBAORTIC STENOSIS

35 REFORMATS

36 AORTIC VALVE PRE/POST-OP

37 TRANSCATHETER AORTIC VALVE IMPLANTATION (TAVI OR TAVR)

38 TAVI- POST-OPERATIVE

39 AORTIC VALVE COMPLICATION

40 AORTIC VALVE COMPLICATION

41 POST-OP ASSESSMENT

42 MITRAL VALVE ASSESSMENT

43 MITRAL VALVE ASSESSMENT

44 MITRAL VALVE IN MOTION

45 Mitral valve leaflet calcification on MDCT indicates mitral valve sclerosis or stenosis. Mahnken AH. AJR 2007; 188:

46 MITRAL VALVE PROSTHESES

47 PULMONIC VALVE ASSESSMENT

48 PULMONIC VALVE ASSESSMENT

49 TRICUSPID VALVE ASSESSMENT

50 TRICUSPID

51 MASSES

52 CARDIAC THROMBUS

53 CARDIAC THROMBUS

54 CARDIAC MASSES Lipomatous Hypertrophy

55 LARGE MASS

56 WHERE S THE MASS

57 CARDIAC TUMOR Hepatoma Liver

58 CARDIAC TUMOR Angiosarcoma

59 CARDIAC TUMOR Right atrial osteosarcoma

60 CONGENITAL HEART DISEASE Valvular» Bicuspid aortic valve» Pulmonic stenosis» Tricuspid (Ebstein s anomaly) Left to right shunts» Atrial septal defect (most common)» Ventricular septal defect» Patent ductus arteriosus Complex» Tetralogy of Fallot» Transposition of great vessels» Miscellaneous Post-operative

61 CT FOR CHD - PRINCIPLES Ideally, adults (radiation concern) Children for optimal 3D recons In younger children» Sedation» Hand injection» Non-gated often» mg/ml concentration

62 ATRIAL SEPTAL DEFECT Most common adult CHD F>M 3:1 Secundum (75%), primum, and sinus venosus types Fatigue, SOB, atrial arrhythmias Consider transcatheter closure

63 VENTRICULAR SEPTAL DEFECT 2 nd most common adult CHD Usually small Membranous, muscular, supracristal Dyspnea, pulmonary HTN Courtesy: L. Haramati MD

64 PATENT DUCTUS ARTERIOSUS Abnormal persistence after 10 days of life Fourth most common adult CHD abnormality Complications» Pulmonary hypertension» CHF» Aneurysm

65 PULMONIC STENOSIS 10% of CHD M=F Dysplastic leaflets Large Left PA, NL R PA due to post-stenotic jet Balloon dilatation

66 TETRALOGY OF FALLOT VSD/RVH Pulmonary Stenosis Aortic override Right aortic arch

67 LV ANALYSIS

68 LV FUNCTIONAL ASSESSMENT Strong correlation between CT and MRI LV function (r> 0.95) Yamamuro Radiology 2005

69 LV FUNCTION/PERFUSION

70 LV FUNCTION/PERFUSION

71 LV FUNCTION/PERFUSION

72 CARDIAC PERFUSION Perfusion defect

73 CARDIAC PERFUSION DEFECT

74 Courtesy: R. Yang MD

75 THANK YOU

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