Coronary CTA. August 23, 2013.

Coronary CTA. August 23, 2014.POOL SOCIETY WEEKENDJayanth H Keshavamurthy, M.D.Assistant Professor of RadiologyGeorgia Regents University.

1. QuestionAn overweight man had CAC SCORE OF 500 last year. He has made significant life style changes since that time. He is now requesting a reevalauation of his cardiovascular risk. What would you recommend?A. Coronary CTA with CAC score.B. Coronary CTA without CAC score.C. CAC score only.D. Neither Coronary CTA nor CAC score.

AnswerD.

TECHNIQUEProspective ECG triggered.120kVPSlice Collimation 2.5 -3mm.Medium sharp reconstruction kernel without edge enhancement- provides moderate image noise.

TECHNIQUEZ axis from carina to base of heart.

FOV is 250 mm.

INDICATIONSRisk stratification in asymptomatic individual. With intermediate Framingham Risk Score.

USEFULNESSIncremental prognostic information.Independent risk assessment over Framingham risk evaluation alone in patients without established CAD.

How is it calcium score calculated?Agatston score is widely used.It is area based.Others have used volume and mass

Coronary calcification is pathognomonic of atherosclerosis and represents an attempt at healing.

Typically pixels with >130 HU (?90HU )are considered to represent calcification.Area of the lesion is multiplied by a coefficient.(1-4).Agatston scores of all lesions are summarized to yield the total Agatston scores per vessel and per patient.

FALLACYDoes not detect non-calcified atherosclerotic plaque.Cannot accurately assess presence or absence of CAD.Gives a crude estimate of atherosclerotic burden.

CC Scores are lower in African American men than in Caucasian men.

Interscan reproducibilty is substantially better for high calcium scores.

Interscan variability is rather high. So follow up testing is not recommended.

Calculate calcium score from CCTA from dual energy in future.

Using iterative reconstruction to reduce dose in future.

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2. Regarding contrast protocol for performing pulmonary vein imaging which one of the following is true.

A. Identical to coronary CTA.B. Requires higher contrast flow rates.C. Bolus tracker should be placed at level of left atrium.D. One should not consider using prospectively ECG triggered CT.

C. Bolus tracker should be placed at level of left atrium.

TECHNIQUEProspective or retrospective ECG gated study .ROI is left atrium.No beta blocker needed as we are not assessing coronary arteries.Patient frequently in A.fib.

ASSESSMENTLA size. Anatomy of pulmonary veins- numbers, variations.Ostial size is measured in Mid diastole to guide catheter sizes for EP ablation. Measured 1 cm from ostia in orthogonal reconstructed view.LAA thrombus vs mixing artefact is differentiated by repeat CT 45-60 seconds later.Relationship to esophagus- VR image provided.

VARIATIONSLA Area 11- 33 cm2.Normal 2 left and 2 right PV.Variations- 1 (common) left and 2 right PV. -2 left and 3 right PV ( separate ostia for middle lobe.)

COMPLICATIONSPV Stenosis.Esophageal perforation.Cardiac tamponade.Throbo-embolism.Phrenic nerve injury.

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3. All the following are coronary veins exceptA. Small cardiac vein.B. Middle cardiac vein.C. Large cardiac vein.D. Great cardiac vein.

C. Large cardiac vein.

CORONARY VEINS

TECHNIQUEImages are obtained 5-10 sec delay after ROI on aorta to allow for coronary venous return.

IMPORTANCETo look for variations and assist in EP procedures like BIVICD Placement.

Also not to falsely confuse a vein as a patent coronary artery.

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What is the diagnosis?

4. Question.What is the diagnosis?A. Coronary aneurysm.B. Coronary ectasia.C. Coronary fistula.D. Coronary dissection

B. Coronary ectasia.

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5. What is the diagnosis? A. Hyper trophic cardiomyopathy.B. Non Compaction syndrome.C. Arrhythmogenic RV dysplasia.D. Ebsteins anomaly.

C. Arrhythmogenic RV dysplasia.

Right ventricular dysfunctionSevere dilatation and reduction of RVejection fractionwith little or no LV impairmentLocalized RV aneurysmsSevere segmental dilatation of the RVTissue characterizationFibrofatty replacement of myocardium on endomyocardial biopsyConduction abnormalitiesEpsilon waves in V1- V3.Localized prolongation (>110 ms) of QRS in V1- V3Family historyFamilial disease confirmed on autopsy or surgeryMajor Criteria

Right ventricular dysfunctionMild global RV dilatation and/or reduced ejection fraction with normal LV.Mild segmental dilatation of the RVRegional RV hypokinesisTissue characterizationConduction abnormalitiesInverted T waves in V2and V3in an individual over 12 years old, in the absence of aright bundle branch block(RBBB)Late potentials on signal averaged EKG.Ventricular tachycardia with aleft bundle branch block(LBBB) morphologyFrequent PVCs (> 1000 PVCs / 24 hours)Family historyFamily history of sudden cardiac death before age 35Family history of ARVDMinor Criteria

ARVD diagnostic criteria There is no pathognomonic feature of ARVD. The diagnosis of ARVD is based on a combination of major and minor criteria. To make a diagnosis of ARVD requires either 2 major criteriaor1 major and 2 minor criteriaor4 minor criteria.

ARVDGenetic Cardiomyopathy.Fibro fatty replacement of RV myocardium.LBBBAutosomal dominant with incomplete penetrance and autosomal recessive inheritance.Positive family history in 30-50%.

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6.Visibility of stent lumen depends on all of the following exceptA. Scanner technology.B. Stent size.C. Stent length.D. Stent lumen.

C. Stent length.

RCA STENT SHARP FILTERRCA STENT MEDIUM FILTER

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7.What is the diagnosis?A. Transposition of great vessels.B. Truncus arteriosus.C. Coarctation of aorta.D. Tetralogy of Fallot.

D. Tetralogy of Fallot with ASD and Cor triatrium.

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8.What syndrome does this patient have?A. Downs syndrome.B. Tuberous sclerosis.C. Von Hippel landau disease.D. Turners syndrome.

B. Tuberous sclerosis.

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9.Patient with history of recent stroke.A. Atrial thrombus.B. LV thrombus.C. Aortic dissection.D. Pulmonary embolism and ASD.

ANSWERB. LV THROMBUS

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10.What is the diagnosis?A. Left atrial thrombus.B. Left atrial myxoma.C. left atrial lipoma.D. Atrial septal aneurysm.

B. Left atrial myxoma.

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11. Using bolus tracking which is ideal attenuation threshold for performing coronary CTA. LOCATIONTHRESHOLDA. Descending Aorta400 HUB. Ascending Aorta300 HUC. Descending Aorta350 HUD. Ascending Aorta150 HU

D. Ascending Aorta150 HU

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12. Second most common cause of sudden death?A. Hypertrophic cardiomyopathy.B. Anomalous origin and course of coronary arteries.C. Arrhythmia.D. Coronary dissection.

B. Anomalous origin and course of coronary arteries.

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13.Triple rule out- simultaneous opacification of coronaries, aorta and pulmonary artery?A. Faster contrast injection rate.B. Larger contrast volume.C. Higher tube current.D. Thicker slice collimation.

B. Larger contrast volume.

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14. Patient has had CABG, LIMA to LAD and SVG to OM. All the following are true regarding coronary CTA exceptA. CCTA has poor accuracy in assessing disease within bypass grafts.B. Radiation exposure is higher than in a CTA evaluating native vessels.C. His native coronaries will likely be heavily calcified which may potentially limit diagnostic accuracy.D. Routine surveillance of bypass graft patency in asymptomatic is not considered appropriate.

A. CCTA has poor accuracy in assessing disease within bypass grafts.

Curved MPR

Straight MPR

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15. What does this 87 year female have?A. Coronary artery fistula.B. Coronary artery dissection.C. Coronary artery aneurysm.D. Coronary artery ectasia.

A. Coronary artery fistula.

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16. Name the artery arising from circumflex coronary artery. Study performed prior to RF ablation.A. S shaped SA nodal artery.B. Obtuse marginal artery.C. AV nodal artery.D. Acute marginal artery.

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17. Name the anomalous artery.A. RCA.B. LAD.C. Circumflex coronary artery.D. SA nodal artery.

ANSWERC. Circumflex of RCA

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18. Name the anomalous artery.A. RCA.B. LAD.C. Circumflex coronary artery.D. SA nodal artery.

ANSWERC. Circumflex artery of right cusp separate ostia.

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19. What is a common pitch for a typical coronary CT angiogram using retrospectively ECG-gated 64 slice CT.A. 0.1B. 0.2C.1.0D. 2.0

B. 0.2

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20. What surgery did this patient have?A. ASD closure device.B. Mitral valve replacement.C. LA appendage clip.D. Tricuspid valve replacement.

A. Amplatz ASD occlusion device.

Thanks toDr. William Bates MD.

Dr. Benett Greenspan MD.

Dr. Gyanendra Sharma MD.