Cardiac CT

A Report of Chang Gung Memorial Hospital in RD

Transcript

1. Cardiac CT LTY,2019 CANON MEDICAL DEBUTS GLOBAL ILLUMINATION 1
2. OVERVIEW ► Anatomy ► Computed Tomography ► Reconstruction&Postprocessing Techniques ► Cardiac CT ► coronary CT angiography (cCTA) ► pediatric cardiac CT ► coronary artery calcium (CAC) ► CAD-RADS 2
3. Anatomy 3
4. Anatomy 4
5. Anatomy 5
6. Anatomy 6
7. Hudsmith LE, Petersen SE, Francis JM, Robson MD, Neubauer S. Normal human left and right ventricular and left atrial dimensions using steady state free precession magnetic resonance imaging 7
8. 1, 2a, 2b : LAD Ao Ascending Aorta(AoA) 升主動脈 AoD aortic dissection 降主動脈 MP main pulmonary artery 主肺動脈 LP left pulmonary artery 左肺動脈 RP right pulmonary artery 右肺動脈 SV superior vena cava 上腔靜脈 RVO right ventricular outflow 右心室出口 LAD left anterior descending 左前降支 8
9. Az azygos vein 奇靜脈 pr posterior right aortic sinus 右後主動脈竇 RAA right atrial appendage 右心耳 RCA right coronary artery 右冠狀動脈 LMCA left main coronary artery 左冠狀動脈主幹 LCx left circumflex 左旋支 GCV great cardiac vein 心臟靜脈 CS coronary sinus 冠狀靜脈竇 1, LAD. 2, LCx. 3, CS. 4, LUL. 5,RUL. 6, SA. 1, LMCA. 2, LCx. 3, LAD. 4, GCV. 1, LAD. 2a, LCx. 2b, CS. 4, RCA. 9 LCx LAD LM
10. Anatomy ► LMCA ► LAD ► D1 ► D2 ► septal branches ► LCx ► M1 ► M2 ► RCA ► AM(RMA) ► AV node ► PDA 10
11. Computed Tomography ► Multislice Computed Tomography ► Dual-Source Computed Tomography ► Dual-Energy Computed Tomography ► single-source dual-energy ► Prospective ECG-gated 11
12. Vendor Scanner model X-ray source— detector design Number of detector rows Detector element z- dimension (mm) Total detector z- axis coverage (mm) Minimum gantry rotation time (ms) Intrinsic TR (ms) X-ray generator power (kW) GE Healthcare, Chalfont St Giles, UK Optima 660 Single 64 0.625 40 350 175 72 Revolution HD/GSI Single 64 0.625 40 350 175 107 Revolution CT Single 256 0.625 160 280 140 103 Philips Healthcare, Guildford, UK Ingenuity Single 64 0.625 40 420 210 80 iCT Elite Single 128 0.625 80 270 135 120 IQon Spectral CT Single 64 0.625 40 270 135 120 Siemens Healthcare, Frimley, UK Somatom Definition Edge Stellar Single 64 0.6 38.4 280 142 100 Somatom Definition Flash Stellar Dual 64 0.6 38.4 280 75 2 × 100 Somatom Force Dual 96 0.6 57.6 250 66 2 × 120 Toshiba Medical Systems, Crawley, UK Aquilion ONE Single 320 0.5 160 350 175 72 Aquilion ONE Vision Single 320 0.5 160 275 137 100 12
13. Multislice Computed Tomography (MSCT) ► 錐狀束 ► 2D陣列式偵檢器 ► Z-axial覆蓋範圍 ► 16>>64>>256/320 ► 單次心跳CTCA ► 256*0.5mm(TOSHIBA,2006, 500 ms per rotation) 13
14. Dual-Source Computed Tomography (DSCT) ► 時間解析度提高 ► 減少移動假影 ► 雙能射源 14
15. Dual-Energy Computed Tomography (DECT, Spectral CT) ► 對比解析度提高 ► 心肌灌注缺陷 ► 冠狀動脈粥狀硬化 ► 射束硬化校正 1. New Applications of Cardiac Computed Tomography: Dual-Energy, Spectral, and Molecular CT Imaging 2. Coronary Stent Patency: Dual-Energy Multidetector CT Assessment in a Pilot Study with Anthropomorphic Phantomt 15
17. ECG-gated ► 回顧式 ► 輻射劑量較高 ► 移動校正 ► 前瞻式 ► 單個心週期內掃描 ► 輻射劑量2-6 mSv 17
18. Reconstruction&Postprocessing Techniques ► Reconstruction ► Iterative ► full ► hybrid ► Filtered Back Projection(FBP) ► Postprocessing ► Motion Correction(GE: SnapShot Freeze) ► Fractional Flow Reserve CT 18
19. Motion Correction (GE: SnapShot Freeze) 19
20. SnapShot Freeze • 多項位影像重建 • 冠狀動脈分割與定位 • 運動特徵 • 補償校正 20
21. Cardiac CT Advancement Evolution of SnapShot Freeze Technology 21
22. Fractional Flow Reserve CT (FFR-CT) 22
23. FFR-CT ► Navier-Stokes 方程式 ► 影像後處理 ► 血液動力學 ► 病變特異性缺血 ► 避免非必要之侵入式冠狀動脈檢查 23
26. 52y, male (A) curved MPR 顯示鈣化斑塊造成LAD50%以上的狹窄 (B) FFR-CT值(0.76)顯示箭頭處病變特異性缺血 (C) Invasive Coronary Angiography白色箭頭顯示阻塞性狹窄，黑色箭頭FFR 值=0.75顯示病變特異性缺血 (D)心臟彩色渲染+FFR-CT影像 26
27. Coronary CT angiography (cCTA) 27
28. Indications ► 評估急性胸痛 ► 先天性心臟疾病 ► 冠狀動脈解剖構造 ► 冠狀動脈鈣化評分 ► 評估冠狀動脈旁路移植術 28
29. Parameters: Calcium Score(C-) ► Tube Voltage: 120kVp ► Tube Current: SURE-Exposure ► R-R Scanning Window: ► HR<71BPM (75%) ► HR>71BPM (40%) ► Slice:0.5mm ► Collimation:240(120mm) ► Rotation time: ► Acquilion One 640: 350msec ► Acquilion One Vision: 275msec Acquisition and Reconstruction Techniques for Coronary CT Angiography: Toshiba Healthcare Scanner Platform 29
30. Parameters: ECG Gated CTA ► 管電壓: 120kVp ► 管電流: SURE-Exposure ► Min mA:40 ► Max mA:580 Acquisition and Reconstruction Techniques for Coronary CT Angiography: Toshiba Healthcare Scanner Platform 30
31. Parameters: Contrast Acquisition and Reconstruction Techniques for Coronary CT Angiography: Toshiba Healthcare Scanner Platform BMI(kg/m^2) 注射速率(mL/s) 總注射量(mL) 20 5 55 20-25 5 60 26-30 5 70 31 5.5 75 32-35 5.5 80 31
32. Pediatric Cardiac CT 32
33. Indications ► 房間隔缺損 ► 室間隔缺損 ► 開放性動脈導管 ► 肺動脈狹窄 ► 右心雙出口 33
34. Parameters ► 管電壓:80kVp ► 旋轉時間:275ms ► 顯影劑:2mL / kg, 300mgI / mL, Omnipaque ► 注射速率: ► <0.5y/o, <5kg 稀釋一半, 0.5mL / sec ► >0.5y/o, >5kg, 1mL / sec ► 影像重建:full iterative Pediatric 320-row cardiac computed tomography using electrocardiogram-gated model-based full iterative reconstruction, 2017 34
35. Coronary Artery Calcium (CAC) 35
36. Coronary Artery Calcium (CAC) ► Agatston Score, 1990 ► 1=131-200HU, 2=201-300HU, 3=301-400HU, 4>400HU ► Volume Score, 1998 ► 基於Agatston使用三維重建 ► Mass Score, 2002 ► HU 轉換為 mg of CaHA/cm3 ► Calcium Coverage Score, 2008 ► 以5mm冠狀動脈計算Agatston與Mass Score Coronary Artery Calcium Score: A Review,2013 36
37. Degree of coronary artery calcification Absolute CAC score (Agatston method) CAC score adjusted for gender, age and ethnicity - percentile Clinical interpretation Absent 0 0 Very low risk of future coronary events Discrete 1-100 ≤ 75 Low risk of future coronary events; low probability of myocardial ischemia Moderate 101-400 76-90 Increased risk of future coronary events (aggravating factor); consider reclas- sifying the individual as high risk Accentuated > 400 > 90 Increased probability of myocardial ischemia Coronary artery calcium score: current status, 2017 37
38. CAD-RADS (Coronary Artery Diseases Reporting and Data System) Ricardo C. Cury, al. CAD-RADSTM Coronary Artery Disease – Reporting and Data System. An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Radiology (ACR) and the North American Society for Cardiovascular Imaging (NASCI). Endorsed by the American College of Cardiology, July, 2016. 38
39. 最大冠狀動脈狹窄程度 解釋 處置 CAD-RADS 0 0％ ACS極不可能 考慮其他病因 CAD-RADS 1 1-24％ ACS極不可能 如果正常肌鈣蛋白和無心 電圖改變，則考慮非ACS 病因預防性治療。 CAD-RADS 2 25-49％ ACS不太可能 如果正常肌鈣蛋白和無心 電圖改變，則考慮非ACS 病因的評估。 進行預防性治療。 CAD-RADS 3 50-69％ ACS可能 ICA評估和管理。 考慮抗缺血和預防管理。 如果存在血流動力學顯著 病變，應考慮其他治療。 CAD-RADS 4 A. 70-99％ B. LMCA> 50％、3支血 管阻塞性疾病 ACS可能 進一步評估ICA和FFR。 應考慮抗缺血和預防管理。 CAD-RADS 5 100％（完全阻塞） ACS非常可能 應考慮盡快ICA及急性閉 塞症 。 應考慮抗缺血。 CAD-RADS N. 非診斷性研究 不能排除ACS 需要對ACS進行額外或替 代評估 ACS – acute coronary syndrome 急性冠狀動脈症狀 ICA – invasive coronary angiography First: modifier N (non-diagnostic) Second: modifier S (stent)支架 Third: modifier G (graft)繞道 Fourth: modifier V (vulnerability)破裂 39
40. CAD-RADS 0 : 無斑塊或狹窄 40
41. CAD-RADS 1 :直徑狹窄小於25％ 41
42. CAD-RADS 1 :直徑狹窄小於25％ 42
43. CAD-RADS 2 :直徑狹窄25-49％ 43
44. CAD-RADS 3 : 直徑狹窄50-69％ 44
45. CAD-RADS 4A :直徑狹窄70-99％ LAD非鈣化斑塊 45
46. CAD-RADS 4B :三支血管> 70％狹窄 46
47. CAD-RADS 4B :LM> 50％狹窄 47
48. CAD-RADS 5 : 完全阻塞 A:近端RCA非鈣化閉塞 B:近端LCx完全閉塞 48
49. REFERENCE ► https://radiopaedia.org ► https://pubs.rsna.org ► James P. O’Brien, al. Anatomy of the Heart at Multidetector CT: What the Radiologist Needs to Know, 2007. ► Lee W. Goldman. Principles of CT: Multislice CT, JNMT, 2008. ► J. of Cardiovasc, Trans. Res, Journal of CardiovascularTranslational Research, 2013. ► James K. Min, MD, al. Noninvasive Fractional Flow Reserve Derived From Coronary CT Angiography, 2015. ► Zahi A.FayadPhD, New Applications of Cardiac Computed Tomography: Dual-Energy, Spectral, and Molecular CT Imaging, 2015. ► Go Shirota, al. Pediatric 320-row cardiac computed tomography using electrocardiogram- gated model-based full iterative reconstruction, 2017. ► Matthias Renker, al. Evaluation of Heavily Calcified Vessels with Coronary CT Angiography: Comparison of Iterative and Filtered Back Projection Image Reconstruction, 2011. ► Ricardo C. Cury, al. CAD-RADSTM Coronary Artery Disease – Reporting and Data System. An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Radiology (ACR) and the North American Society for Cardiovascular Imaging (NASCI). Endorsed by the American College of Cardiology, July, 2016. 49