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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