Introducing a new

imaging for coronary

artery using MSCT.
Latihan singkat ct cardiac./ct-angio
 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(60-70%)
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 yearscome 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
 Spatial resolution
(diameter coronary artery 2-4mm.)
3mm
3

1mm
1 0,75mm
0,6mm
0,2mm
0
EBCT 4 16 64 angio
 40 Scan time

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 painCAD, 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.
 Patient’s 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; SVG2-
Distal LCX.
 3D volume rendering images
How we interpret coronary CTA ?
 1. Calcium score assessment
 2.coronary artery assessment of the RCA-PDA;
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 recommendation
0 no atherosclerotic plaque healthy diet,stop
CAD risk very low smoking.
1-10 minimal plaque burden ,
CAD risk low +tight control of
DM and hypertension,
consider of using statin.
11-100 mild plaque burden,
CAD risk moderate +statin,aspirin
101-400 moderate plaque burden
CAD risk high +exercise program,
folic acid, vit.E
> 400 extensive plaque burden +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 PDA =0 LAD=0 LCX=0 ,

Total calcium score= 0 unit.
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