Utilizzo clinico della cardio-TC: l’esperienza del Centro Cardiologico Monzino Gianluca Pontone, MD Centro Cardiologico Monzino, IRCCS, Milan, Italy Department of Cardiovascular Sciences, University of Milan, Italy BACKGROUND 1400 1200 CARDIAC CT 1000 CORONARY ARTERY DISEASE 800 CARTOMERGE 600 400 PULMONARY VEINS 200 CARDIAC VENOUS SYSTEM 0 2004 2005 2008 ANNO CT BODY CT CARDIAC CT 2009 4782 3075(64%) 1707 (36%) SUMMARY LightSpeed16 1st MicroVoxel imaging CT 16-strati LightSpeed Ultra 1st TAC 8-strati LightSpeed Plus 2001 1st TAC 4-strati con velocità subsecond variabile LightSpeed QX/i 1st TAC 4-strati Novità rivoluzionaria per la TC 1998 2002 2000 2004 ACCURACY OF MDCT: critical role of HR ACCURACY OF MDCT: critical role of HR We enrolled enrolled 500 500 consecutive consecutive patients patients We Evaluationof ofcoronary coronaryvessels vessels>>1.5 1.5mm mm Evaluation Evaluationof of149 149arterial arterialCABG CABG Evaluation Evaluationof of153 153venous venousCABG CABG Evaluation Feasibility CABG: CABG: 99% 99% Feasibility Feasibility coronary coronary Feasibility vessels: 97% 97% vessels: ACCURACY OF MDCT: critical role of HR Limitation of of 16 16-slices scanner Limitation -slices scanner Metallic clips SVG>Int. Distal anastomosis Distal Vessels ACCURACY OF MDCT: critical role of HR Feasibility Coronary Coronary Artery: Artery: 96% 96% Feasibility CFX Misalignement of slices (58 pts) GCV CS Calcified Plaque (13 pts) Interference of cardiac veins (10 pts) ARTIFATCS HR<55 bpm 55>HR<65 HR>65 bpm Misalignment = = Premature Beats = = Calcified Plaque = = = Cardiac Veins = = PV MCV IVP ACCURACY OF MDCT: pre-test likelihood of CAD ACCURACY OF MDCT: pre-test likelihood of CAD GROUP 1 Prevalence < 50% 116 PATIENTS Chest Pain features Gender Age GROUP 2 Prevalence 50% MDCT ICA Diamond GA N Engl Med 1979 MDCT ICA ACCURACY OF MDCT: pre-test likelihood of CAD Sp: TN/(TN+FP) ACCURACY OF MDCT: pre-test likelihood of CAD • Male, 52 years old, with history of hypertension, smoker, symptomatic of chest pain during the effort, persistent after the interruption of the effort.. ACCURACY OF MDCT: pre-test likelihood of CAD • Male, 78 years old, symptomatic of typical angina but not responsive to nitrates. ACCURACY OF MDCT: complementary role of stress test ACCURACY OF MDCT: complementary role of stress test 144 (pts) with angina pectoris Exercise-stress test (ExECG) Atypical Angina Typical Angina Ex-ECG negative Group 1 Group 2 Ex-ECG positive Group 3 Group 4 MDCT Coronary angiography (QCA) ACCURACY OF MDCT: complementary role of stress test ACCURACY OF MDCT: complementary role of stress test GROUP 1 Atypical Angina Ex-ECG negative Diagnostic Work-up without CT • 71% ICA useless Diagnostic Work-up with CT • Reduction ICA 70% • 10% ICA useless ACCURACY OF MDCT: complementary role of stress test J Thoracic Imaging 2008 in Press 1A 1B LIMA 1C LIMA LIMA T RCA T T LMA LAD 1D 1E PA 1F T LIMA T A T 2A LMA 2B 2C PLA RCA LAD RCA LCX PDA PDA 2D 2E 2F RCA LCX LAD LMA LMA ACCURACY OF MDCT: complementary role of stress test Male, 66 years old, undergoing to CT for ablation of pulmonary veins in history of paroxismal atrial fibrillation ACCURACY OF MDCT: complementary role of stress test ACCURACY OF MDCT: complementary role of stress test LCX *: p < 0,05 Group 1 (DCM) Group 2 (Control) Number 61 139 Feasibility 97,2% 96,1% Sensitivity 99% 86,1%* Specificity 96,2% 96,4% NPV 99,85 96,4%* PPV 81,2% 86,1% 10 out of 61 pst presented complications during ICA No complications were described during MDCT LM D1 LAD M1 ACCURACY OF MDCT: complementary role of stress test GROUP 1 Atypical Angina Ex-ECG negative GROUP 2 Typical Angina Ex-ECG negative Diagnostic Work-up without CT • 71% ICA useless Diagnostic Work-up with CT • Reduction ICA 70% • 10% ICA useless Diagnostic Work-up without CT • 30% ICA useless Diagnostic Work-up with CT • Reduction ICA 16% • 16% ICA useless ACCURACY OF MDCT: complementary role of stress test Male, 44 years old, symptomatic for typical angina with Ex-ECG and nuclear stress test negative ACCURACY OF MDCT: complementary role of stress test GROUP 1 Atypical Angina Ex-ECG negative GROUP 2 Typical Angina Ex-ECG negative GROUP 3 Atypical Angina Ex-ECG positive Diagnostic Work-up without CT • 71% ICA useless Diagnostic Work-up with CT • Reduction ICA 70% • 10% ICA useless Diagnostic Work-up without CT • 30% ICA useless Diagnostic Work-up with CT • Reduction ICA 16% • 16% ICA useless Diagnostic Work-up without CT • 27% ICA useless Diagnostic Work-up with CT • Reduction ICA 24% • 12% ICA useless ACCURACY OF MDCT: complementary role of stress test Female, 44 years old with hypertension, atypical angina, ex-ECG positive and stress nuclear test positive in inferior wall of LV ACCURACY OF MDCT: complementary role of stress test GROUP 1 Atypical Angina Ex-ECG negative GROUP 2 Typical Angina Ex-ECG negative GROUP 3 Atypical Angina Ex-ECG positive GROUP 4 Typical Angina Ex-ECG positive Diagnostic Work-up without CT • 71% ICA useless Diagnostic Work-up with CT • Reduction ICA 70% • 10% ICA useless Diagnostic Work-up without CT • 30% ICA useless Diagnostic Work-up with CT • Reduction ICA 16% • 16% ICA useless Diagnostic Work-up without CT • 27% ICA useless Diagnostic Work-up with CT • Reduction ICA 24% • 12% ICA useless Diagnostic Work-up without CT • 5% ICA useless Diagnostic Work-up with CT • Reduction ICA 5% • 5% ICA useless ACCURACY OF MDCT: complementary role of stress test Male, 65 aa with history of myocardial infarction of inferior wall of LV LV * * ACCURACY OF MDCT: complementary role of stress test ACCURACY OF MDCT in CABG evaluation “Ideal vessel” - Great diameter - Relative spatial fixation - Usually free of severe calcification ACCURACY OF MDCT in CABG evaluation ACCURACY OF MDCT in CABG evaluation ACCURACY OF MDCT: critical role of HR Feasibility CABG: CABG: 99% 99% Feasibility SVG>M0 LIMA>LAD High accuracy in the evaluation of CABG patency SUMMARY LightSpeed16 1st MicroVoxel imaging CT 16-strati LightSpeed Ultra 1st TAC 8-strati LightSpeed Plus 2001 1st TAC 4-strati con velocità subsecond variabile LightSpeed QX/i 1st TAC 4-strati Novità rivoluzionaria per la TC 2002 2000 • Low Heart Rate 2004 • Intermediate pre-test of CAD 1998 • Chest Pain/Stress test discordance • DCM • CABG • Left Atrium BACKGROUND VCT XT/e 2008 LightSpeed VCT XT Snapshot pulse Volume shuttle Lightspeed VCT 64 strati 2004 2006 2006 An unusual case of punctiform chest pain An unusual case of punctiform chest pain X-Ray revealed the presence of a foreign body in the form of needle at the level of the cardiac shadow (red circle) An unusual case of punctiform chest pain CT indicated the presence of a “needle” running through the whole tickness of the anterior wall of the left ventricle to the anterior leaflet of the mitral valve that was involved by fibrous thickening. MDCT-64 slices and DCM MDCT-64 slices and DCM CS GCV GCV MCV GCV PV LMV PV AIV LMV LEGENDS CS: coronary sinus; MCV: middle cardiac vein; PV: posterior vein; GCV: great cardiac vein; LMV: left marginal vein; AIV: anterior interventricular vein. MDCT-64 slices and DCM Ischemic DCM patients present less cardiac veins than other group ACCURACY OF MDCT in ISR restenosis AJC 2010 ACCURACY OF MDCT in ISR restenosis ACCURACY OF MDCT in ISR restenosis AJC 2009 • 100 patients (88 men, 12 women, 64 ± 10 years) • 179 stent, mean diameter: 3.14 ± 0.59 mm • HR: 58±9 bpm (metoprolol in 76%) • MSCT and ICA (QCA) in 100 patients • IVUS in 24 patients ACCURACY OF MDCT in ISR restenosis Segment-based analysis Patient-based analysis Feasibility 95% 91% Sensitivity 87% 85% Specificity 98% 96% PPV 92% 93% NPV 96% 92% Accuracy 95% 92% ACCURACY OF MDCT in ISR restenosis N. Feas Se Sp PPV NPV Acc. 99 80 96% 93% 92% 84% 96% 100% 78% 100%* 99% 92% 96% 95% 27 144 74% 99% δ 67% 89% 78% 100% δ 57% 100% δ 85% 97% δ 75% 98% 73 106 96% 94% 94% 80% 100% 96% 100% 84% Θ 98% 95% 98% 93% Stent type DES BMS Stent diameter < 3.0 mm ≥ 3.0 mm Strut thikness < 100 μm ≥ 100 μm * p<0.05 vs DES δ p<0.05 vs <3.0 mm Θ p<0.05 vs < 100 μm ACCURACY OF MDCT in ISR restenosis N. Feas Se Sp PPV VPV Acc. 134 45 94% 98% 79% 100% * 97% 100% 86% 100% 95% 100% 94% 100% 52 127 94% 95% 88% 88% 94% 99% 88% 96% 94% 97% 92% 97% 62 117 98% 93% 67% Θ 93% 98% 97% 86% 93% 94% 97% 93% 96% Stent material Stainless steel CoCr alloy Cell Shape Open cell Closed cell Bifurcation/ Overlapping Overlap + Overlap - * p<0.05 vs Stainless steel Θ p<0.05 vs overlap - ACCURACY OF MDCT in ISR restenosis Proximal RCA Stent Restenosis ACCURACY OF MDCT in ISR restenosis Proximal RCA Stent Restenosis SUMMARY VCT XT/e 2008 • DCM LightSpeed VCT XT • Stent Snapshot pulse Volume shuttle 2006 Lightspeed VCT 64 strati 2004 2006 2007 Low Dose MDCT 1) Helical retrospective ECG-gating • • • • coll 64 X 0.625mm rot time 0.35 msec 700 mA, 120 kv pitch 0.2:1 • Total X-Ray exposure time 6 sec 2) SnapShot Pulse – Axial prospective ECG-gating • coll 64 X 0.625mm • rot time 0.35 msec • 700 mA, 120 kv • Total X-Ray exposure time 1.9 sec “ in the prospective ECG gating the table remains stationary while the X-ray tube rotates aorind the patiemt and, only when data acqusition is completed the table is advanced for the susequent scan “ Low Dose MDCT Low Dose MDCT Low Dose MDCT Radiation Dose Report Group 1: Effective Dose padding 0 msec: 3.8 mSv Effective Dose padding 100 msec: 5.8 mSv Group 2: Effective Dose: 20.5 mSv ICA: Effective Dose: 6 - 9 mSv SUMMARY VCT XT/e ED: 5.8 mSv • DCM LightSpeed VCT XT • Stent Snapshot pulse Volume shuttle Lightspeed VCT 2008 2006 64 strati 2004 2006 2007 2008 “Ultra” Low Dose MDCT BMI<20 BMI<25 BMI<30 BMI<35 BMI35 100 KVp 100 KVp 100 KVp 120 KVp 140 Kvp 500 mA 550 mA 600 mA 650 mA 700 mA “Ultra” Low Dose MDCT Evaluability and Diagnostic Accuracy of a Low Radiation Exposure Protocol for Prospective ECG-Triggering Coronary Multidetector Computed Tomography Angiography in detection of coronary artery disease Accuracy of a Low Radiation Exposure protocol Gianluca Pontone, MD, Daniele Andreini, MD, Antonio L. Bartorelli, MD, FACC, Alberto Formenti, MD, Erika Bertella, MD, Andrea Annoni, MD, Saima Mushtaq, MD, Sarah Cortinovis, MD, Daniela Trabattoni, MD, FACC, Piero Montorsi, MD, Giovanni Ballerini, MD, Piergiuseppe Agostoni, MD, PhD, Cesare Fiorentini, MD, Mauro Pepi, MD Centro Cardiologico Monzino, IRCCS, Milan, Italy Department of Cardiovascular Sciences, University of Milan, Italy Submitted “Ultra” Low Dose MDCT Number of patients, n Noise, HU (mean±SD) SNR(mean±SD) CNR(mean±SD) Segment-based analysis Patient-based analysis Effective Dose (mSv), mean ±SD GROUP 1 GROUP 2 p 70 33.98.0 14.5±4.3 16.0±4.6 95 (94-97) 97 (93-100) 67 26.85.0 14.2±4.1 16.5±4.4 94 (92-96) 99 (96-100) p = ns P<0.01 p = ns p = ns p = ns p = ns 2.11.2 7.5±1.8 p<0.001 “Ultra” Low Dose MDCT Effective Dose: 1.7 mSv “Ultra” Low Dose MDCT “Ultra” Low Dose MDCT Effective Dose: 2.2 mSv “Ultra” Low Dose MDCT “Ultra” Low Dose MDCT Effective Dose: 3.2 mSv SUMMARY VCT XT/e ED: 5.8 mSv • DCM LightSpeed VCT XT • Stent Snapshot pulse Volume shuttle Lightspeed VCT ED: 2.1 mSv 2008 2006 64 strati 2004 2006 2007 2008 MDCT High Definition THANK YOU Spatial Resolution: 0.23FOR mmATTENTION Discovery HD 750 2009/10