Cardiac CTA Toshiba AquilionONE

Cardiac CTA Toshiba AquilionONE Gated Volume Scan Mode IMG 12122 Cardiac Prospective IMG 12123 Cardiac Retrospective IMG 12119 Cardiac ED Chest Pain A B Patient Position Supine Feet First into Gantry Heart Isocenter Scanogram AP and Lateral A Non-Contrast Calcium Score Scan ECG Gated Scan For calcium scores > 600 Contact the cardiac team resident or the radiology resident on call to determine need for contrast scan. HU Monitor position in center of volume scan ROI on descending aorta SS trigger HU 200 B Contrast Scan ECG Gated Scan Injection Rate 5 ml / sec preferred IV Size and Location 18g, 20g min RT AC preferred Contrast Omnipaque 350 Saline Amount equal to contrast amount Respiration Breath Hold Acquisition Specs 0.5 mm Thickness 0.275 sec rotation / 0.35 sec rotation Place and size scan over chest to include carina through bottom of heart. Scan max length- 16 cm--may be reduced by increments of 2 cm. B For prospectively triggered scan, set exposure range To Next R to ensure proper diastole exposure during scan. A Non-Contrast Calcium Score Calcium Score Exposure and Reconstruction: For heart rate < 75 bpm, images will be reconstructed 75% For heart rate > 76 bpm, images will be reconstructed 40% Post processing done at workstation. See instructions below. B Contrast Scan for Coronary Arteries Scan Options: Prospectively Triggered Scan Image reconstruction is limited to the exposed range of the beat. Set scan exposure range To Next R to insure proper diastole exposure during scan. Use this exposure for: Patients with heart rates in range for a 1 beat scan Retrospectively Gated Scan Image reconstruction is available for the total beat. Functional analysis (CFA) data is available with this scan and is programmed in the scan protocol. Use this exposure for: Post Heart Transplant Patients with heart rates that are too high for a 1 beat scan

Reconstruction -Volumes and Images Images from Non-Contrast Volume 1 Calcium Score These are programed in the protocol. A Algorithm R1 Thickness Spacing Transfer Cardiac Ca Score 3 mm 3 mm 220 mm ON- PACS and PCS_TS 220 mm dfov Images from Contrasted Volume 1 75% and Best Phase are programed in the protocol and will reconstruct automatically. B Algorithm R1 Thickness Spacing Phase Transfer Cardiac CTA 0.5 mm 0.25 mm 220 mm Best Phase + Window ImageXact if needed ON- PCS_TS only B For Functional Analysis if available R2 Algorithm Cardiac CTA Thickness 1.0 mm Spacing 1.0 mm 220 mm Phase CFA 0% - 90% Every 10% Transfer ON- PCS_TS only 220 mm dfov Contrasted Volume 2 for Large dfov B Algorithm Cardiac CTA V2 Thickness may use default Spacing may use default 320 mm Transfer OFF Images from Contrasted Volume 2 for Large dfov B Algorithm Cardiac CTA R3 Thickness 3 mm Spacing 3 mm 320 mm Series Description Large dfov Transfer ON- PACS and PCS_TS Phase 80% Large dfov

Reconstruction CTA --Vessel Analysis In Raw Data, select contrast volume series, click Load Click ECG, check ECG for accurate R wave indicators. To modify red markers: left click on red dot, then left click on proper placement. To discard a beat: Left click below ECG wave. A blue line will appear indicating that this beat is not going to be used in the reconstruction process. If changes are made, click Save, Close, and then Close again. If no changes are needed, click Close. ECG screen shot will automatically transfer to PACS. Settings in Volume Tab Slice thickness 0.5 mm Interval 0.25 mm Reconstruction phases Best Phase + Window Transfer PCS_TS only Click Recon For Functional Analysis, if data available, Click CFA. Reconstruct 0% - 90% every 10%, 1 mm x 1 mm. Volume and Image Reconstruction for Extra-Cardiac Structures-Large D Settings in Volume Tab Turn Transfer OFF Slice thickness 1.0 mm Interval 1.0 mm Size 320 mm Click Cardiac Phase CTA Recon Phase 80% Settings in Multi View Tab Axial Slice thickness 3.0 mm Interval 3.0 mm Series description Large D select in drop down box Transfer PACS and PCS_TS Click Recon Vessel Analysis with ImageXact --This is OPTIONAL and only used if requested. In Raw Data, select contrast volume series, click OK Click ECG, check ECG for accurate R wave indicators, Click Save, Close, and then Close again. Click on Cardiac ImageXact. Main Tab Yellow bar on ECG must be located within the beat being used for reconstruction. To move yellow bar, type correct seconds in Recon Position Sec box Detail Tab Cardiac CTA Phase Interval 2% Select one slice location that best demonstrates the three main coronary arteries, Click Next. This slice will be reconstructed for one cardiac cycle at 2% intervals. Review these images to find the % (s) that have the least motion. Click Select Phase to enter these in the reconstruction list. Reconstruct a minimum of 3 phases- One for each major coronary artery: LAD, RCA, and Cx. Click Next Thickness: 0.5 mm Interval: 0.25 mm Transfer PCS_TS only Click Recon

Generating the Calcium Score on the fx Workstation For calcium scores > 600 Contact the cardiac team resident or the radiology resident on call to determine need for contrast scan. Open the patient folder in the directory. Load the calcium score series with 54 images and 3mm x 3mm thick/spacing. This series may be named CALCIUM SCORE Cardiac Ca Score or simply 75%. Click Load Volume. In the Gallery tab click Pick button on 2D Vscore with Color. Click on the appropriate vessel name in the left column. Use the cursor to circle calcium for each coronary vessel. Repeat this process for each axial slice of the scan. When all calcium is identified, click on Snap. Left click to create snapshot. If patient has no calcium, use cursor to create circle in lung tissue area. This will create the score chart as if the patient had calcium. Proceed to Report tab. Send all graphs and snapshots to PACS by clicking Export and Archive / PACS.

RCA LAD CX LAD RCA CX

Guidelines for Medication Administration for Cardiac CTA The target heart rate for cardiac CTA is 66 bpm or less. Communication with the Cardiac Team is required for any deviation of these guidelines. Please call ext 45691 Monday through Friday, 8AM-4PM, and ext 44385 evening and night hours. See Practice Guidelines, under the Patient Care tab at http://xray.ufl.edu for more information. Out-patient Cardiac CTA Monday through Friday, scheduled in AM appointment slots. The out-patient scheduled for cardiac CTA is managed by our Radiology Department nursing staff. The patient is taken to the Radiology Care Unit for preparation after check-in at the Radiology CT desk. The cardiac team resident/attending will provide orders in EPIC for the following: Beta blocker: IV Metoprolol Dose: 4 doses, 5mg each Administered by RN just prior to scan Sublingual Nitroglycerine Dose: 0.4mg Administered 3-6 minutes prior to contrasted scan In-patient Cardiac CTA Weekdays Monday through Friday, 8AM 4PM The in-patient scheduled for cardiac CTA is managed by our Radiology Department nursing staff. The charge technologist should contact the Radiology Care Unit to discuss availability of nursing staff. The cardiac team resident/attending will provide orders in EPIC for the following:. Beta blocker: IV Metoprolol Dose: 4 doses, 5mg each Administered by RN just prior to scan Sublingual Nitroglycerine Dose: 0.4mg Administered 3-6 minutes prior to contrasted scan In-patient Cardiac CTA Weekends Saturday and Sunday, 8AM 4PM The in-patient scheduled for cardiac CTA on the weekend is managed by the hospital floor/unit nursing staff. The ordering physician will provide orders for oral metoprolol. Dose: 100mg Beta blocker: Oral metoprolol given 1 hour prior to scan or until target heart rate of 66 bpm is reached. ED Patient with Chest Pain The Emergency Department patient scheduled for cardiac CTA is managed by the ED nursing staff. The ordering physician will provide orders for oral metoprolol. Dose: 100mg Beta blocker: Oral metoprolol given 1 hour prior to scan or until target heart rate of 66 bpm is reached.

Guidelines for In-Patient Cardiac CTA See Practice Guidelines, under the Patient Care tab at http://xray.ufl.edu for more information. Or call Cardiac Reading Room: ext. 45691, Body Reading Room ext. 44385 with questions. Criteria for Cardiac CTA Patient felt to be low to intermediate pretest likelihood of having coronary ischemia as a cause of chest pain. Appropriate Indications for Cardiac CTA Chest pain in low to intermediate risk patient Chest pain in low to intermediate risk patient with borderline or mildly abnormal ETT Patient with possible coronary anomaly Ordering Cardiac CTA and Beta Blocker Administration Cardiac CTA order may be placed at any time. The exam will be performed 8AM 4PM on weekdays and weekend days. Weekdays Monday through Friday Physician will place order for Cardiac CTA in EPIC Correct orderable: CT Angio Cardiac Coronary Arteries The in-patient scheduled for cardiac CTA is managed by our Radiology Department nursing staff. The charge technologist should contact the Radiology Care Unit to discuss availability of nursing staff. Beta Blocker Administration Weekdays Beta blocker: IV Metoprolol 4 doses, 5mg each Administered by radiology staff RN just prior to scan. Sublingual Nitroglycerine 0.4mg Administered by radiology staff RN 3-6 minutes prior to contrasted scan. The cardiac team resident/attending will place order in EPIC for IV metoprolol and sublingual nitroglycerine. The exam will be coordinated by the CT charge tech and the floor or unit nursing staff. Weekends Saturday and Sunday Physician will place order for Cardiac CTA in EPIC Correct orderable: CT Angio Cardiac Coronary Arteries The ordering physician will place order in EPIC for oral metoprolol. 100mg The ordering physician will contact the radiology resident. Cardiac Reading Room: ext. 45691 Body Reading Room: ext. 44385 Beta Blocker Administration Weekends Beta blocker: 100mg oral metoprolol Until target rate of 66 bpm is met. The patient s nurse will report to CT the time that the beta blocker was given. The Cardiac CTA should be done when the target heart rate of 66 bpm is met. The exam will be coordinated by the CT charge tech and the floor or unit nursing staff.

IV Access for Cardiac CTA 18g PIV preferred, 20g PIV min Order of location preference: Right AC Right mid forearm Left AC Left mid forearm All other locations are unacceptable for contrast bolus delivery for cardiac CTA. Other lines or catheters must be approved by the Cardiac Imaging Team or the radiologist/resident on call. Please see IV Access Guidelines under the Patient Care tab at http://xray.ufl.edu for more information. Contraindications for Cardiac CTA Inability to hold breath or cooperate Cardiac CTA performed within the last year Increased cardiac enzymes Creatinine level > 1.8. Acute EKG changes Pregnancy History of severe contrast reaction Arrhythmia Renal insufficiency Multiple myeloma Sickle cell anemia Pheochromocytoma Calcium Score For calcium score values below 600, the contrast scan will be completed and the patient returned to the floor For calcium score values above 600, the contrast scan may be cancelled by radiology The cardiac team or the radiology resident on call will notify ordering physician of this change Reporting of Results Weekdays Monday Friday, 0800 1600 hrs 1 hour: full report available Monday Friday, 1600 0800 hrs After 0800: full report available Weekends Friday 1600 hrs Monday 0800 hrs..full report available after daily read-out

CTA Pediatric Chest Gated with IV Contrast IMG 14099 For patients over 50 lb, see CTA Peds Chest Gated Child, page 2 For patients with history of Fontan procedure, see page 3. CTA Peds Chest Gated Infant Pediatric Patients up to 50 lb AqONE Protocol Location: Pediatric, Group A, Left Side Column See page 3 for heart rate conversion information and indications for this exam. Patient Position Supine Contrast Visipaque 320 See contrast chart below Scan Mode Target Volume Gated CTA Beats 1 Scan Slice Thickness 0.5 mm Scan Slice Spacing 0.25 mm kvp 80 ma SUREExposure Exposure Window *Use heart rate chart below to set factor Target % **Use heart rate chart below to set factor Scan Coverage Place volume over chest to include 2cm above apices and 2cm below heart. Volume sizes available 8cm, 10cm, 12cm, 14cm, 16,cm Use shortest scan range possible while covering required anatomy. Heart Rate Chart * ** Heart rate bpm Ex Window Target % 150-170 350 ms 50% 120-150 450 ms 60% 120 and lower 500 ms 70% Contrast Chart Weight Contrast Use 10 ml syringes for contrast 0 10 lb 1 ml per lb Rapid hand inject 11 49 lb.75 ml per lb Rapid hand inject Reconstructions are programmed in the protocol and will reconstruct automatically. Algorithm FC12 Soft Tissue Thickness 0.5 mm Spacing 0.25 mm Include ribs Phase 70% Transfer PACS and PCS_TS Algorithm FC12 Soft Tissue and Lung Thickness 2 mm Spacing 2 mm Include ribs Phase 70% Transfer PACS and PCS_TS

CTA Peds Chest Gated Child Pediatric Patients 50 to 75 lb AqONE Protocol Location: Pediatric, Group A, Right Side Column Use Adult Cardiac CTA protocol and adjust exposure factors accordingly for: Patients over 75 lb Patients with exam indication for coronary artery evaluation See next page for heart rate conversion information and indications for this exam. Patient Position Supine Contrast Visipaque 320 See contrast chart below Scan Mode Target Volume Gated CTA Beats 1 2 50 60 lb 61 75 lb Scan Slice Thickness Scan Slice Spacing 0.5 mm 0.25 mm kvp 80 ma SUREExposure Exposure Window *Use heart rate chart below Target % **Use heart rate chart below BT HU ROI placed on descending aorta 180 Scan Coverage Place volume over chest to include 2cm above apices and 2cm below heart. Volume sizes available 8cm, 10cm, 12cm, 14cm, 16,cm Use shortest scan range possible while covering required anatomy. Heart Rate Chart * ** Heart Rate bpm Ex Window Target % 150-170 350 ms 50% 120-150 450 ms 60% 120 and lower 500 ms 70% Contrast Chart Weight Contrast and Saline > 50 lb 0.5 ml per lb Power inject 2 ml/sec Reconstructions are programmed in the protocol and will reconstruct automatically. Algorithm FC03 Soft Tissue Thickness 0.5 mm Spacing 0.25 mm Include ribs Phase 70% Transfer PACS and PCS_TS Algorithm FC03 Soft Tissue and Lung Thickness 2 mm Spacing 2 mm Include ribs Phase 70% Transfer PACS and PCS_TS

Heart Rate Conversion Information Heart Rate to Millisecond Conversion: Heart Rate 60 = 1000ms (R to R segment) HR = 60 R to R (sec) = 60 R to R(msec) = 60,000 R to R (in sec) HR HR Heart Rate 60 65 70 75 80 85 90 95 100 120 130 140 150 160 170 ms 1000 923 857 800 750 705 666 631 600 500 462 428 400 375 353 INDICATIONS Aortic anomaly Coarctation Pulmonary artery anomaly Pulmonary venous anomaly Systemic venous anomaly CTA Pediatric Chest Gated for patient with history of Fontan procedure For infant or child under 75 lb, use above pediatric chest gated protocol and repeat the volume scan at 70 seconds post contrast injection. For patients over 75 lb, use the adult CTA Chest PE protocol for Fontan procedure. Fontan conduit should look similar to this. Other Options for Fontan Visualization listed below.

**Use only when instructed by radiologist** Instruction for Dual Injection Upper PIV and Lower PIV For pediatric patients below 50lb. Upper PIV should be right sided antecubital preferred Lower PIV may be located on either side Inject lower extremity with 2/3 of total contrast amount, hand inject rapid When lower injection is 2/3 complete, start upper extremity injection with remaining contrast, hand inject rapid Start scan immediately at end of injection Instruction for Contrast / Saline Mix - Upper PIV ONLY PIV should be right antecubital Inject 100% contrast at 3ml/sec for 125 ml Immediately follow at 2ml/sec with 50% contrast, 50% saline mix for 25 ml Bolus track: manual/visual on Fontan conduit Scan A: Start scan upon visual conformation of contrast in PA Second Scan B: Repeat first scan 70 sec from start of contrast injection

Pediatric NPO and IV Guideline for Cardiac CT NPO Requirement Pediatric patients are to be NPO for 4 hours prior to contrast injection. A pediatric patient may be told to arrive after being NPO for two hours. Do not delay getting the patient worked up and getting IV access as it may take a considerable amount of time to get these tasks done. It is most favorable that the patient wait after IV access is obtained to meet policy guidelines for NPO status. This reduces the overall delay if there are problems with IV access. IV Access PIV Placement PIV Size Never use scalp IV access for this exam Optimal: 22 g Optimal: Upper extremity Acceptable: 24 g Acceptable: Lower extremity PICC Lines Umbilical access is not permitted for this exam Minimum 3 Fr. single lumen The CT technologist/lpn will attempt no more than 2 times to gain IV access. If unsuccessful, the following staff should be contacted in the order listed. 1. Flight Team 50222 If the flight team is unsuccessful, call Pediatric Cardiology 273-7600, to inform that the patient has been delayed due to IV access difficulties. 2. Charge RN NICU 5-0033 3. Charge RN 10-2 5-6102 4. Charge RN PICU 5-1004 5. STAT RN beeper 413-4574 If you have exhausted all possibilities, call the ordering physician. In the event that the physician is unavailable, call Dr. Chandran 871-0519