Introducing a new

imaging for coronary

artery using MSCT.
Patricia M.Widjaja,M.D.
Department of Radiology,
HUSADA Hospital, Jakarta.
Hotel Nikko 17
Feb.2007

Introduction

It has been known for long that Computed

Tomography (CT) scan is the modal imaging
for brain and body. No suitable imaging for
cardiac because continues heart beat made
conventional CT impossible to scan the
entire heart in just one breath hold.
one-third of all conventional coronary
angiographic examinations in the United
States are performed in conjunction with an
interventional procedure, while the rest(6070%) are performed only for diagnostic
purposes,that is only for verification of the
presence and degree of CAD .( CT of Coronary
Artery Disease. U. Joseph Schoepf, MD, Radiology 2004;232:18-37.)

Refinements in computed
tomographic (CT) angiography of the
coronary vessels have enabled the
minimally invasive detection of
coronary artery stenoses, with high
sensitivity and specificity
To date, calcium score (CS) and CT
angiography (CTA) have been used
almost exclusively to screen patients
for risk of coronary artery disease
or risk of future cardiac events .

Coronary Artery Stenoses: Detection with Calcium Scoring, CT Angiography, and

Both Methods Combined . George T. Lau,et al, (Radiology 2005;235:415-422.)

The development of
CT scan in the past
30 yearscome to
role in cardiac
imaging.

History of CT scan
1971: Hounsfield discovered and
menufactured first CT SCAN (EMI Mark 1-Head scan).
1974: whole body (ACTA)
1974:3rd generation CT scan(Artronix)
1977: 4th generation CT scan (AS&E scanner)
1979:Nobel prize to Hounsfield and Cormack.
1983:dynamic spatial reconstruction
1983:electron beam CT scanning(EBCT)
1987:CT with continously rotating tube

1989:Spiral CT scan
1991:dual slice spiral CT( elscint)
1991 : CT angiography
1995:CT real time reconstruction/CT
fluoroscopy
1998:Multislice CT(4-detector rows)
1999:Multislice cardiac imaging
2001/2:Multislice 8/16 detector rows
2004 : multislice 32/64 detector rows
Future: cone beam CT (>128 detector
rows

The development of CT scan from single slice spiral

CT to multislice CT make available for cardiac
imaging.
MSCT with high temporal resolution(TR) possible
to cover the heart in one breath hold.
In 1980, using cardiac-gating in spiral CT not
successful.Because the TR is still low.
MSCT with high spatial resolution possible to
visualize small caliber of coronary artery .
The technology in cardiac CT then conquered by
MR which provides cardiac software for cardiac
imaging and the presence of electron-beam
CT(EBCT) in mid 1980.
Experience in EBCT makes scientists develop MSCT
for cardiac imaging.

Temporal resolution
250ms
200ms
160ms
100ms
4

16

64

EBCT

3mm

Spatial resolution
(diameter coronary artery 24mm.)

2
1mm

0,75mm
0,6mm

0
EBCT

16

64

0,2mm

angio

Scan time

40
30
sec

20
10
5
4

EBCT

16

64 MDCT

The principle of Coronary CTA

To provide good result heart beat must
under 60 bpm and regular.
Need good synchronization between scan
time and heart beat motion . Therefore , we use
ECG gating to synchronize the scan and heart
beat.
There are two types of gating used in cardiac
MSCT :

Prospective

gating use for calcium score

Retrospective gating use for image
reconstruction in coronary artery.

CTA coronary artery

has some limitation, to provide

good result :

1. heart beat must under 60 bpm and regular.

2 need good synchronization between scan

time and heart beat motion .
Therefore ,
we use ECG gating to synchronize the scan
and heart beat.
3.patient must be able to hold the breath for
5-8 second in 64 MSCT and 18-20 second in
16 MSCT.
4.the use of iodine contrast in some patient
may cause unpleasant allergic reaction.
5.avoid doing MSCT in patient with allergic
history, renal failure and stop the use of
metformin in diabetic patient 2 days prior
the examination.

Radiation dose

CTA Coronary
6 15 mSv
CT Calcium Scoring ~0.6 mSv
Cardiac Catheterization 1 10 mSv
Nuclear scan
Tc-99m (rest only) 4 5 mSv
Tc-99m (rest+stress)
9 13 mSv
Tl-201 (rest+stress)
~34 mSv
Natural Background (Annual)3 mSv

Work station for cardiac CT

Indication and patient selection

CAD risk factor required to have a coronary

CTA.
Primary CAD risk factor:
Cigarette smoking
Hypertension
Elevated LDL (>130mg/dl)
Low HDL( < 40 mg/dl)
Diabetes mellitus
Family history
Assesment post by-pass graft
Anomali vascular.
Triple rule out in chest painCAD, dissecting
aorta (DA) and pulmonal emboli (PE)

Preparation for coronary CTA

Fasting 6 h before , avoid coffee 12 h before.

Sign an inform consent.
Check the heart rate and blood pressure.
If the heart rate >60 bpm give beta blocker
( tab.Lopresor 100mg.),wait for 30-60 minutes.
Check heart rate every 10-15 minutes.
Beta blocker can be repeated after one hour, if the
heart rate still above 60 bpm.
Patients comfortable and calm are very important.
The examination is not suitable for stress or anxiety
patient and irregular heart beat.
Diabetic patient using metformin must be
discontinued 2 days before and 1 day after exam.

Protocol Coronary CTA

Pasien in supine position, feet first.

Infusion is installed using abocath 18G in the left
v.cubiti.
Put ECG gating and monitor.
scanogram for heart-scan localization.
Prospective gating for Calcium scoring .
Timing bolus to determine the scan delay time.
Nitroglycerin spray sublingual just before the
scan.
Oxygen to help breath hold.
CTA coronair used power injector, 80-100ml
iodine contrast, 5ml/sec in one breath hold ( 5
second) follow by 50cc saline chaser.

Proses dan pencetakan

Calcium scoring
Curve imaging: RCA,LAD dan LCX
Vascular tree
MIP images :Origo RCA,LM;
RCA,LAD,LCX.
MIP Images penting pada post by pass
graft. : LIMA-RIMA, SVG, RVG.

mis: LIMA-Distal RCA atau SVG1-Mid LAD; SVG2Distal LCX.

3D volume rendering images

How we interpret coronary CTA ?

1. Calcium score assessment

2.coronary artery assessment of the RCAPDA; LM-LAD(first and second diagonal)LCX(marginal branch)
Caliber and vascular wall
Degree and location of vascular
stenosis ( below/above 50%)
Location of Calcium plaque, soft plaque.
Anomali vascular, dominant vascular,
collateral vascular.
3. Myocardium .
4. Ancillary finding in the lung and
mediastinum.

Rekomendasi penanganan pasien berdasarkan calcium score

Calcium score
risk
0
no atherosclerotic plaque
CAD risk very low
1-10
minimal plaque burden ,
CAD risk low

11-100
101-400

> 400

mild plaque burden,

CAD risk moderate
moderate plaque burden
CAD risk high
extensive plaque burden

recommendation
healthy diet,stop
smoking.
+tight control of
DM and hypertension,
consider of using statin.
+statin,aspirin
+exercise program,
folic acid, vit.E
+stress test,coronary
angiography

Prognosis in calcium score

In 2000,The American College of Cardiology together with

American Heart Association , base on EBCT calcium score in
correlation with prognosis of CAD :
1.Zero

calcium score: possibility of

atherosclerosis plaque is very low, no
evidence of CAD.
2.positive calcium score:confirm the
present of CAD.
3.high calcium score: possibility of
vessel disease is high .
4. Severe calcium score : consistent
with moderate-to-high risk CAD in 2-5
years.

Impression of the interpretation:

. Normal CTA : rutine check up

2. Mild Coronary Artery Disease:
Recommend the patient to consult a cardiologist
for risk factor assessment and possible statin
+aspirin therapy.
3. Moderate CAD:
Consult cardiologist for statin and aspirin therapy
as well as a nuclear stress test.
4. Severe CAD:
Recommend for heart catheterization

Contoh hasil

64 MSCTA coronary artery dibuat dengan snap short program

pada HR 65-70, tanpa dan dengan kontras iodum injeksi.

Calcium score : LM= 0

RCA=0
,
Total calcium score= 0 unit.

PDA =0

LAD=0

LCX=0

Origo RCA dan LM baik.Tidak tampak anomaly vaskuler.

RCA: kaliber vaskuler baik, dinding vaskuler licin, tidak
tampak calcium/soft plaque, tidak tampak focal
stenosis. Opasifikasi vasuler baik. Distal RCA memberi
cabang PDA dan PLB sesuai dengan right dominant
coronary arteri.
LM pendek, bifurcatio LAD-LCX baik. Tampak ramus
intermediate(RI) diantaranya, RI pendek dan tebal.

LAD : kaliber vaskuler baik, dinding vaskuler licin,

tidak tampak calcium/soft plaque, tidak tampak
focal stenosis. Opasifikasi vasuler baik. First dan
second diagonal branches baik.
LCX: kaliber vaskuler baik, dinding vaskuler licin,
tidak tampak calcium/soft plaque, tidak tampak
focal stenosis. Opasifikasi vasuler baik. Left
marginal branch baik.
Tidak tampak aneurysma atau collateral vaskuler.
Tidak tampak kelainan di mediastinum .
KESAN: Normal CTA coronary artery, total calcium
score 0 unit. Tidak tampak vessel disease atau
stenosis vaskuler.
Right dominant coronary artery.

Severe CAD,calcium score

> 500 units.

tn.HS,69th.
Riwayat AMI,
hiperlipidemi

16 and 64 slice MSCT : 3D vascular

tree

Post CABG

Stenosis proximal
LAD

Heavy soft plaque/trombus with total occlusion distal RCA

Tn.RW,60th.Riw.perokok,DM,Chol.
Keluhan: tidak ada, rajin jalan pagi .

CA:stenosis proximal LAD and LCX

Summary

The development of 16 later 64

slices made MSCT possible to scan
the entire heart in just one breath
hold and so will increasing the role of
MSCT in cardiac imaging in the future.

With high spatial and temporal

resolution it is possible to visualized
small caliber of coronary artery and
to freez the heart.

MSCT has high negative predictive value

(99%) , means if CTA coronary is normal,
almost certain the coronary angiography
will also be normal, while the positive
predictive value of MSCT is low ( 75-95%) ,
especially in heavy calcified plaque, CT can
not assess adequately the vessel stenosis
due to blooming effect of the calcium.
>16-MSCT has open a new field for
radiologist to be involved in cardiac imaging
. Together with the cardiologist we should
work together in harmony and build
friendly competition to provide the best
outcome for the benefit of the patient.

CTA coronary does not

meant to
replace coronary
angiography
CTA coronary is a screening
modality in CAD risk patient with
no symptom.
In patient with high risk coronary
heart disease and high calcium
scoring, it is better to proceed for
direct coronary angiography .

THANK YOU
pmw,feb.2007