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* CT Cardiac
* http://www.radreport.org/template/0000008

Type: Reporting template

Language: English (en)
Modified date: 2012-07-19
Creator: Jacobs JE, et al.
Contributor: Bozkurt S [coder]
Contributor: Kahn CE Jr [editor]
Contributor: North American Society for Cardiac
Imaging (NASCI)
This file is part of the "RSNA Radiology Reporting
Templates."

The RSNA Radiology Reporting Templates are

licensed without charge under
the RSNA's license agreement (the "License"); you
may not use this file
except in compliance with the License
(http://www.radreport.org/license.pdf).

Unless required by applicable law or agreed to in

writing, software
distributed under the License is distributed on an
"AS IS" BASIS, WITHOUT
WARRANTIES OR CONDITIONS OF ANY KIND, either
express or implied.

See the License for the specific language governing

permissions and
limitations under the License.

Copyright (c) 2013, Radiological Society of North

America, Inc. (RSNA)
ALL RIGHTS RESERVED

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RSNA CCTA TEMPLATE

Clinical Indication: [#] year old [woman |man] with

coronary artery disease risk factors of
[hyperlipidemia; hypertension; diabetes;
autoimmune disease; prior MI; prior stroke;
smoking history; family history of heart disease]
presenting with [exertional angina; atypical chest
pain; chronic chest pain; shortness of breath; arm
pain; jaw pain; palpitations; ECG changes; prior
abnormal single photon emission computed
tomography study; prior abnormal
echocardiogram; heart failure; cardiomyopathy;
pre-surgical assessment] for evaluation of the
presence of coronary artery disease.

Comparison studies: [type; date]

Imaging Technique: A [#]-slice multidetector

computerized tomography coronary angiogram
was obtained using [prospective | retrospective]
ECG gating. [{only insert this sentence if
retrospective ECG gating was used}ECG tube
modulation [*was used to reduce the radiation
exposure | was not used because of arrhythmia|
was not used because of the need for systolic and
diastolic imaging]. The coronary CT angiogram was
performed with [#] mL of [type] contrast
administered intravenously. Imaging was
performed from the level of the [pulmonary artery
bifurcation | carina] to the level of the
hemidiaphragms. In order to provide better
evaluation of the anatomy and disease process,
advanced off-line 3-D post-processing techniques,
including [multiplanar reconstruction; maximal
intensity projections; curved reconstructions; and
volume rendering] were performed. {If a calcium
score has been performed, the technique and
results should also be included in the CT
angiogram report}.

Medication administered in preparation for the

examination:
- blocker: [[#] mg [type] p.o. x [#] doses]; [[#]
mg [type] IV x [#] doses] for heart rate/rhythm
control
[Calcium channel blocker: [#] mg [type] IV x [#]
doses for heart rate/rhythm control]

Nitroglycerin: [* 0.4] mg SL [*spray | tablet] for

coronary vasodilation

{Describe any pre-examination steroid preparation

or Benadryl administration here for contrast
allergy}

Vital Signs: Before medication administration, the

heart rate was [#] beats per minute and the blood
pressure was [#] mm Hg. Upon discharge, the
heart rate was [#] beats per minute and the blood
pressure was [#] mm Hg.

Procedure Complications/ Allergic reactions:

[*none].

Radiation Dose: The CT dose index-volume was [#]

mGy, and dose length product of the examination
was [#] mGy-cm.

Coronary CT Angiogram Quality: The overall quality

of the CT angiographic examination is [excellent|
good| fair | poor | nondiagnostic] and is limited by
[poor arterial opacification; misregistration
artifacts; patient motion; calcium blooming
artifacts; metal artifact; arrhythmia].

Coronary Artery Angiogram Findings:

Stenoses are reported as maximum percentage
diameter stenosis.
Stenosis grading is reported using the following
scheme:
Normal: no stenosis
Mild: 1-49% stenosis
Moderate: 50-70% stenosis

Severe: >70% stenosis

Occluded

Dominance of the coronary artery system: [*right |

left | co-dominant] with [*normal | anomalous]
origins and course.

Left Main: The left main is a [*normal | small]

caliber vessel which gives rise to the [* LAD and
circumflex arteries | LAD and circumflex arteries as
well as a ramus intermedius artery {if this option is
chosen, the qualities of the ramus intermedius
branch need to be reported}]. The left main [has
no stenosis | has mild stenosis | has moderate
stenosis | has severe stenosis | is occluded | is
nonevaluable] with [no | noncalcified | mixed |
calcified] plaque. {If present, stents should be
described by size (if known), type (if known),
number, and segmental location. Any relation to
the adjacent branch vessel ostium should be
described. In addition, the stent should be
described as patent, occluded, or stenosed. Any instent stenosis, fracture, or calcification should also
be described}

Left Anterior Descending Artery: The proximal left

anterior descending artery and first diagonal
branch [have no stenosis | have mild stenosis |
have moderate stenosis | have severe stenosis |
are occluded | are nonevaluable] with [no |
noncalcified | mixed | calcified] plaque. The middistal LAD, D2 and D3 branches [have no stenosis |
have mild stenosis | have moderate stenosis | have
severe stenosis | are occluded | are nonevaluable]
with [no | noncalcified | mixed | calcified] plaque.
[There is a [short | long] [superficial | deep]
myocardial bridge in the [proximal; mid; distal]
segment]. {If present, stents should be described
by size (if known), type (if known), number, and
segmental location. Any relation to the adjacent
branch vessel ostium should be described. In
addition, the stent should be described as patent,
occluded, or stenosed. Any in-stent stenosis,
fracture, or calcification should also be described}

[The ramus intermedius branch [has no stenosis|

has mild stenosis | has moderate stenosis | has
severe stenosis |is occluded |is nonevaluable] with
[no | noncalcified | mixed | calcified] plaque].]

Left Circumflex Artery: The left circumflex artery

and its obtuse marginal [and left posterior
descending artery; and left posterolateral]
branches [have no stenosis | have mild stenosis |
have moderate stenosis | have severe stenosis |
are occluded | are nonevaluable] with [no |
noncalcified | mixed | calcified] plaque. {If present,
stents should be described by size (if known), type
(if known), number, and segmental location. Any
relation to the adjacent branch vessel ostium
should be described. In addition, the stent should
be described as patent, occluded, or stenosed. Any
in-stent stenosis, fracture, or calcification should
also be described}

Right Coronary Artery: The right coronary artery

and acute marginal [and right posterior descending
artery; and right posterolateral] branches [have no
stenosis | have mild stenosis | have moderate
stenosis | have severe stenosis | are occluded | are
nonevaluable] with [no | noncalcified | mixed |
calcified] plaque. {If present, stents should be
described by size (if known), type (if known),
number, and segmental location. Any relation to

the adjacent branch vessel ostium should be

described. In addition, the stent should be
described as patent, occluded, or stenosed. Any instent stenosis, fracture, or calcification should also
be described}

Cardiac Morphology:
The right atrium is [*normal | dilated]. The right
ventricle is [*normal | dilated | hypertrophied]. The
left atrium is [*normal | dilated]. The left ventricle
is [*normal | dilated | hypertrophied]. [There are
features of [an interatrial septal defect | an
interventricular septal defect | an interatrial and
interventricular septal defect | a patent foramen
ovale]. The pericardium is [*normal | thickened |
calcified] and there is [*no | a small | a moderate |
a large] pericardial effusion. The aortic valve [* is
tricuspid | is congenitally bicuspid | is functionally
bicuspid] with [*normal leaflets | leaflet thickening |
leaflet thickening and calcification] [and [*there is
no evidence for motion abnormality | regurgitation
| stenosis] {reported only if retrospective ECG
gating has been used}]. The mitral valve leaflets
are [*normal | thickened | thickened and calcified]
[and [*there is no evidence for motion abnormality

| prolapse of the [anterior; posterior; anterior and

posterior] leaflet | a flail [anterior; posterior;
anterior and posterior] leaflet | stenosis] {reported
only if retrospective ECG gating has been used}].
The heart is [*well separated from | abuts] the
sternum.

[Cardiac Function {reported only if retrospective

ECG gating has been used}
The calculated left ventricular ejection fraction is
[#] %, the left ventricular end-diastolic volume is
[#] mL, and the left ventricular end-systolic volume
is [#] mL. There [are no regional wall motion
abnormalities | is [hypokinesia | akinesia |
dyskinesia] of the [basal; mid ; apical; apex]
[anterior wall; anterolateral wall; anteroseptal wall;
lateral wall; inferolateral wall; inferoseptal wall;
septal wall; inferior wall] of the left ventricle.]

[Cardiac Devices and Indwelling Central Venous

Lines: {the presence of a pacemaker, central
venous line, etc should be discussed here}]

Extracardiac findings:

The [main; right; left] pulmonary artery is [*normal;

enlarged; stenotic]. There [are | are no] filling
defects in the [lobar; segmental; subsegmental]
pulmonary artery branches consistent with
pulmonary arterial embolism. The visualized
thoracic aorta is [*normal | enlarged]. {If the aorta
is enlarged, dissected, or transected: size, location,
and description should be dictated especially for
findings of acute aortic syndromes.} The [*lungs;
right upper lobe; right middle lobe; right lower
lobe; left upper lobe; lingual; left lower lobe] [* are
normal | is consolidated | is atelectatic | has a [#]
mm nodule | has a calcified granuloma]. The
included portion of the upper abdomen [* is normal
| demonstrates a [small | moderate | large] sized
hiatal hernia | [other]].

Impression:
1. [*Normal coronary CTA without evidence for
coronary artery stenosis | Abnormal coronary CTA
with []]. {Describe the important coronary CTA
findings here. If a calcium score was performed,
the total score should also be included in the report
impression.}

2. [* Normal | Abnormal] global and regional wall

motion and function of the LV. {If abnormal give
pertinent findings here.}
[3. {Any additional pertinent cardiac findings.}]
[4. {Any non-cardiac pertinent findings including
lung nodule recommendations. If a lung nodule is
described without known malignancy, a statement
of the Fleishner Society guidelines for appropriate
follow-up should be included in the dictation.}]

Result Communication:
[Dr. [name] | Dr. [name]s assistant [name] |
[other] was notified [by telephone | in person] of
the [*study findings | critical result] at [time] on
[date] and they acknowledged receipt of the result.
{If this was a critical result, the appropriate critical
result guidelines of your institution should be
followed.}]