Cardiac Acquisition

Successful Cardiac CT Acquisitions

Steady HR
Acq Mode matches HR
Uniform Contrast
Proper Alignment
No Motion
No Breathing

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Do No t iD stribute
Ma y 1, 2006
Cardiac Acquisition

Prospective and Retrospective

Gating techniques

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Gating Techniques
Gating Techniques
Prospective Gating – less dose
•Smartscore on all multi-slice systems
•CTA on VCT XT and CT 750 HD
Retrospective Gating – higher dose
•Smartscore on pre multislice systems
•CTA – all scanners prior to VCT XT
- or where the patients HR is >65bpm
Why we need Gating at all?

The heart is moving very quickly, we therefore need to

capture an image at a particular point in the heart
cycle, obtaining motion free images
Under normal circumstances end Diastole 70-75%
of the R-R interval is a good imaging point, the heart is
relatively Still.
Gating Techniques - ECG
Just because the object is moving doesn’t
mean we can’t get a good picture!
Cardiac Motion

Up/down motion of the AV plane

Thickening/thinning of the myocardium
Twisting/untwisting
The coronaries “ride on top” of it all
Approx 250 ms quiescent period in mid-diastole
Bicuspid AV. HR 62 bpm
How to “stop” cardiac motion?

• Faster gantry rotation speed

• Motion compensation
• Appropriate use of the acquired data
Calcium Scoring
SmartScore – Prospective gating
SmartScore – Prospective gating
SmartScore – Scan protocol
•Slice thickness 2.5mm Axial Cine
8 or 16 images per rotation
20 or 40 mm beam
•DFOV 25cm
Do not change the DFOV – the algorithm Needs 25cm, so that the pixel
size is always Constant (0.4mm)
If the DFOV is not 25cm, the SmartScore software
Will warn you that the score may be inaccurate!
CT Angio

So the patients heart rate is 73 bpm and Beta blockade

cannot be given for clinical reasons.
Do we scan using prospective or retrospective Gating??
CT Angio
Retrospective gating

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Helical Acquisition - CTA

Segment Recon uses the minimum amount

Of data required to generate an image. This
is ~ 2/3 of the data from a gantry rotation
(180 degrees + fan angle)
SnapShot Segment ( Retrospective Helical)
 Cardiac Helical – Retrospectively Gated Reconstruction
4-Image X X X X X X X X X X X X X X X X X X X X X X X X X X X X
Locations Z

3-EKG
Signal Cycle 1 Cycle 2 Cycle 3 Cycle 4 Time

View Regions
used by Recon
2-Continuous
View Stream
Multiple Detector Rows
Low-Pitch Helical Scan Views

1-Helical
acquisition
20 /
GE Title or job number /
8/7/2014
Helical scan modes

VCT heart rate ranges

Cardiac Scan Types - Option
Cardiac Scan Types – all the optional cardiac scan types are listed
under Scan Type / Cardiac mode button.
Helical Pitch
During Cardiac scanning The helical pitch will
Change Automatically depending on the patients
heart rate.

It is very important to use the correct pitch

To avoid ungated or badly gated images

The pitch is locked ready for the acquisition at the

time the “confirm”Button is selected
Helical Pitch selection– VCT & VCT XT
Helical Pitch Override
Watch the HR during Scouts and SmartScore

Does the HR change from the value seen at

rest to a different value on breath hold ?

Does the heart rate drop sufficiently to require

A different pitch selection?

If yes – you need to override the pitch setting, or

Press Confirm on breath hold.
Pitch Override

In the gating window turn override ON. Enter the lowest number
in the heart rate group according to your patient’s rate
Single and
Multiphase Imaging
Single and multiphase imaging

Single phase exam

Reconstruction centered at 75% of R-R Interval
Single and multiphase imaging

Multiple data-sets taken at 10%intervals throughout the R-R cycle

Multiphase imaging
Why do we need multiple phases (time points)?
•Functional Analysis
•Where 75% does not prove to be the best data
Set and coronary motion is seen in the images
•Often if diastole is not the best, then images at
Systole (35-40%) will be good especially for the
Right coronary artery
CT Angio
So the patients heart rate is 55 bpm
Do we scan using prospective or retrospective
Gating??
Do we need to consider anything else other
than
Just the absolute heart rate ??
Cardiac CT Prospective gating
How does it work?
How is it achieved?
What is the Flexibility?
LightSpeed VCT XT / 750HD/Optima CT 660

• SnapShot Pulse is a single sector

recon – 175ms
SnapShot Pulse is recommended for
Heart Rates of 65BPM or less
SnapShot Pulse
 Cardiac Scan Types - Option
Cardiac Scan Types – Cardiac Helical (SnapShot Segment, SnapShot Burst, SnapShot Burst+)
modes are acquired with a continuous x-ray during table movement while Cardiac Cine
(SnapShot Pulse) is a step and shoot mode where x-ray is only on for the size of the acquisition .

X-ray ON
How it differs from Helical?
Retrospectively Gated Cardiac Helical (RGH) – SnapShot Segment/Bust

Continuous, low-pitch table feed

Helical with Prospectively ECG-modulated Tube Current / mA

Prospectively Gated Axial (PGA) – SnapShot Pulse “Step and Shoot”

Table move Table move

x-ray exposure 38 /
GE Title or job number /
8/7/2014
Padding
SnapShot Pulse – padding provides additional phase information to account
for some variation in heart rate by adding time before and after the center of
the acquisition window. The padding range is 0-200msec.

SS-Pulse acquisition window, center phase ± msec padding for one R-R interval.
 Flexibility = Padding

•System automatically selects a padding value based on heart rate to support variation in heart rate during
acquisition.
•Padding is added to both sides of the acquisition window.
•Padding range is 0 to 200msec. Dose reduction compared to Cardiac Helical modes. Amount depends on heart
rate and padding for the acquisition.
SnapShot Pulse and Padding
• Padding is automatically applied
• The padding can be over ridden
Impact of Padding on DOSE
120 KV 0.35sec 600 mA – 14cms SNAPSHOT PULSE

Dose differences with Padding 50ms - 4.02 mSv

100ms - 5.22mSv
125ms - 5.83mSv
200ms - 7.63mSv
Retrospective Helical
120KV 0.35sec ECG mA Mod. 120 – 600 / phase 70 – 80% - 14 cms (762 DLP) 12.95mSv
SnapShot Pulse
SnapShot Pulse – retro recon will display a list of phases that are common to
all the rotations. This phase range will depend on the stability of the heart
rate during acquisition and the amount of padding prescribed.

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Arrhythmia Management
Adaptive Gating
High Definition Cardiac
Bypass assessment with unstable heart rate

ECG Report showing the adaptive gating

Technique
Scanner: Discovery CT750 HD
• SnapShot Pulse w/adaptive gating
• 55 BPM w/PVC
• 120 kVp
• 625 mA
• BMI: 26 kg/m2
•Dose: 4.3 mSv* (309 mGy.cm) Highly calcified left coronary Anastomosis of the mammary artery
and the left coronary
Dr. Sablayrolles • Centre Cardiologique du Nord • St. Denis,
France
 High Definition Cardiac
CAD assessment with arrhythmia

SnapShot Pulse w/adaptive gating

• Average HR: 65 BPM, 56 min , max 121

Dr. Sablayrolles • Centre Cardiologique du Nord • St. Denis, France

High Definition Cardiac
SnapShot Pulse with ECG Editor

Courtesy of Dr. Earls, Fairfax Radiology .

 High Definition Cardiac
CAD assessment with a high heart rate and arrhythmia

ECG report before modification

Heart VR with steps due to high

heart rate variation

Technique
Scanner: Discovery CT750 HD ECG Report after editing
Acquisition Mode: Cardiac Helical
Mode
• Average HR: 73 BPM, min 57, max
126
• Tube Voltage: 120 kVp Heart VR after ECG editing
• Tube Current: 740 mA
Basics of Coronary assessment
Best phases for coronary study
•If HR<70 bpm: best phase for RCA
and LCA is 70%-80%
•If HR> 70 bpm: 80% for LCA
40% for RCA

When HR is low, only diastolic phase is

needed for coronary artery assessment

If HR is high, systolic phase is needed

whatever the temporal resolution, this is
physiological
What method do we choose?

•Retrospective helical

•Prospective SnapShot pulse

Retrospective Helical CTA – Multiphase data used:-

• For functional studies

• Multiphase data usually reconstructed
5 or 10% intervals of R to R peaks
• Heart rates >65bpm
• Unstable heart rates (even in the lower ranges!)
• Prospective Cine – Snapshot Pulse:-
• Heart rates <65bpm
Adjust Padding according to requirements
Are Lower heart rates better?
- less phases to review
- Less images to archive and network
- Quicker work flow
- Dose saving
- Aggressive ECG mA modulation
- Snapshot pulse
- LCA, CX, RCA in diastole
* Obtained by EUR-16262 EN, using a chest factor of 0.017*DLP
Practice makes perfect
So does scanning with SnapShot Assist
Selection of optimum phase
and dose.
The intelligence of end-to-end
scanning and reconstruction
adapted to each patient
Helping physician lower dose
while optimizing the diagnostic
value
"Choosing the optimal protocols in cardiac CT can be complex. With experience, a CT technologist learns how to
adjust scanning based on the patient's condition on the table. Expert guidance can reduce the complexity and
improve the chances of a diagnostic outcome.“ – David Dowe, M.D. Atlantic Medical Imaging
54 /
8/7/2014
SnapShot Assist: Simplifying the cardiac scan
Advanced cardiac feature
Build

Faster, easier clinical routine

Your site’s own protocols
Optimize

Setup and reconstruction

Scan type – heart rates and
variability
Exposure – patient weight and
size
Efficient routine scanning
Guide

Patient specific configuration

Consistent results
55 /
8/7/2014
High Heart Rate ?
Introducing Calcium FREEdom

Worlds First Cardiac 70 kev

Spectral imager

HAP(Iodine) Iodine(HAP)
Images Courtesy Dr. Panse, Mayo
Calcium challenges the visualization of vessels
Ex Vivo Extracted Heart
120kVp CAG

Images Courtesy of Prof. Kuribayashi, Keio University

Calcium Blooming ?
Challenge: Beam hardening artifacts mimic myocardial perfusion
defects*

Artifact or defect?
Beam hardening artifact
resulting in an apparent
perfusion defect in patient
without coronary artery *Signal density of left ventricular myocardial segments and impact of beam hardening artifact: implications for
myocardial perfusion assessment by multidetector CT coronary angiography. Rodrı´guez-Granillo et al, Int J
disease Cardiovasc Imaging (2010) 26:345–354
Beam Hardening
Contrast
Delivery and timing methods
Contrast Timing

Contrast needs to be timed accurately, There

Are 2 methods available

•MIROI (Multi Image Region of interest)

•SmartPrep
Contrast Timing – MIROI
• Scout
• SmartScore / Non-Contrast Series
• Timing Bolus
• Cardiac Angio
Select MIROI Location
Chose your location
From the Smartscore Images

3 images above the origin of

LT Main Stem.

or from the Scout

2cm below Carina.
Timing Bolus Parameters

•Rotation time : 1 sec

•Interscan Delay : 1 sec
•Therefore acquire an image every 2 secs
Timing Bolus Parameters

Plan number of images according to patient.

Those with poor cardiac output will require
A longer scan window
Then allow all planned images to scan
To breath or not to breath !!!!
For some patients, the action of holding their
Breath causes Val-Salva.

This means that when injecting a small volume

of contrast – this is blocked from reaching
the Aorta while the breath is held. Therefore no
contrast will be seen on the images until they
breath Normally !

To get around this – scan with the patient breathing

gently.
To breath or not to breath !!!!

Prep delay – if using a prep delay make a

Note of it………………..
Injection Protocol (MIROI)
•20mls Contrast
Injected at the same rate as will be used
For the Angio
•20mls Saline
Injected at same rate as contrast
Producing Timing Graph

•Select measurements
•Select MIROI (Multiple Image ROI)
•Place ROI on the Aorta
•Press OK
Producing Timing Graph
Choosing pre-scan delay
Using previous Graph – Peak enhancement is
18 secs.

Pre-scan delay = peak Enhancement + 6 secs !

(For VCT 64)

Type 24 secs into pre-scan delay

Note : If you have used a prep delay, don’t

forget to also add that to the peak.
Contrast Timing – SmartPrep

Cardiac scan protocol:

• Scout
• SmartScore / Non-Contrast Series
• Cardiac angio
Contrast Timing – Smart Prep
Smart Prep location

Smartprep location – same as MIROI

2cm below the carina
Sequence of events
Monitor phase

Click Monitor Phase, check the pump and be ready

to start the injection and the scan at the same time
The first image will appear after the beginning of the injection
Depending on the monitoring delay set – usually @ 8 seconds
Opacification
Opacification

Good filling of the

Coronaries and Lt
ventricle,
Washout of Rt ventricle
/

MIROI or Smart Prep ???????

There is no right or wrong !!

The decision depends upon your preference !
MIROI is possibly a more repeatable, robust
method to use in the first instance as
it is a step by step process.
However if you are a confident SmartPrep
User, then you may prefer to use it.
Breath-hold
Breath-hold and heart rate

During manual breath-hold ask the

patient to breath in few seconds
before the scan start
Injection protocols
Injection protocols
CT Injectors + Protocols
• Single Phase (Contrast
only)
• Dual Phase (Contrast &
Saline)
• Tri - Phase (Contrast +Mix
saline & Contrast)
Injection protocols
Principle of tri phasic injection protocol

Phase I : 100% of iodine based

contrast medium
Phase II : 50% / 50%
Phase III : 100% of injection
of isotonic solution
Injection protocols
Injection protocols using MIROI
•Load the Dual headed pump with:

•100mls contrast (20mls for MIROI / 75 mls for Angio)

•70mls Saline (20mls for MIROI / 50mls for Angio)
Tri - Phasic
•90mls contrast (20mls for MIROI / 65 mls for Angio)
•95mls Saline + (20mls for MIROI / 25mls saline + 25 mls contrast
mix for Angio)
•50mls Saline

Flow rates 4 – 6mls per second

Injection protocol using SmartPrep
•100 mls Contrast
•50 mls Saline
Injected at 6mls per second
High Definition Cardiac
SnapShot Pulse w/ASiR
0.75 mSv* 0.71mSv* 0.5 mSv*

DLP 54 DLP 51 DLP 36

Dose: 0.75mSv* Dose: 0.71mSv* Dose: 0.5mSv*

Jonathan Leipsic , MD St Paul Vancouver Canada Courtesy of James Min, MD Cornell University Courtesy of James Earls M.D. Fairfax Virginia

* Obtained by ICRP using a chest factor of 0.014*DLP

High Definition Cardiac
Low dose CCTA with ASiR
0.56mSv* 0.57mSv*

F 69 SSP
F 110 SSP 0.68 mSv
HR 42-44 bpm HR 46-50 bpm
80 kVp 80 kVp
600 mA 600 mA
DLP 40.37 DLP 40.78
Courtesy of Dr Leipsic St. Paul’s Vancouver Canada
*Obtained by ICRP using a chest factor of 0.014DLP
High Definition Cardiac
Low dose CCTA with ASiR…0.46mSv*

SnapShot Pulse
100kVp 275mA
Dose: 0.46 mSv*

Obtained by ICRP using a chest factor of 0.014DLP* Courtesy of Dr Leipsic St. Paul’s Vancouver Canad
High Definition Cardiac
Low dose CCTA with ASiR
0.31mSv* 0.47mSv*

F 79 BMI 16.17
F 91 BMI 15.7
Length: 104mm
Length: 104 mm
0.47mSv
0.31mSv
100 kVp, 190 mA
100 kVp, 140 mA
DLP 34.2
DLP 22.24

*Obtained by ICRP using a chest factor of 0.014DLP