Triple-Rule-Out

Helena Hänninen, MD, PhD Consulting Cardiologist

Associate Professor in Cardiology Associate Head of the Department

Department of Cardiology Heart and Lung Center

Helsinki University Hospital

The Triple-Rule-Out team: Dr Reija Västrik and HUS Cardiac Imaging Team

Reija Västrik Associate Professors

Miia Holmström and Sari Kivistö

Differential diagnostics of chest pain

Life-threatening:

– Aortic dissection

– Pulmonary embolism

– Acute coronary syndrome

– Tension pneumothorax

– Cardiac tamponade

– Ulcus perforation

– Esophagus rupture

Not life-threatening reasons:

– Myocardial and pericardial inflammation / pathology

– Pneumothorax

– Lung or pleural infection/other pathology

– Musculoskeletal diseases

– Esophagitis

– Gastric ulcus

– Irritable bowel syndrome

– Cholecystitis

– Pancreatitis

– Psychosomathic

– Etc

Pretest probability of coronary artery disease

Stirrup JE and Underwood SR. The ESC Textbook of Cardiovascular Imaging

Myocardial ischemia

The ESC Textbook of Cardiovascular Imaging

TRO CT-angiography

• Chest area CT-angiography that is performed single-phased with biphasic contrast injection

• Designed for acute chest pain patients to diagnose/exclude three most significant life-threatening diseases

– Pulmonary embolism

– Aortic dissection

– Coronary artery disease

• In Helsinki method upper abdominal organs are also included to FOV

Chest pain

+ dyspnoea

+/- upper abdomen pain Atypical pain Pretest likelihood of CAD low or intermediate

ECG neg Troponin, Ck Mb neg ECHO: normal wall motion

TRO CTA

CCTA

Coronary angiogram

pulmonary CTA

One of these positive: ECG Troponin, Ck Mb ECHO: wall motion abnormality

Pretest likelihood of CAD low or intermediate

Aortic dissection?

aortic CTA

Acute coronary syndrome?

Imaging and patient selection

mTRO: How?

pulmonary CTA Coronary + aortic CTA

mTRO CTA Images: Reija Västrik

”High-quality TRO” Coronary arteries and aorta > 300 HU

Pulmonary arteries > 200 HU

Left pulmonary artery 364 HU

Ascending aorta 366 HU

Left main coronary artery 368 HU Abdominal aorta 295 HU Descending thoracic aorta 303-355 HU

Images: Reija Västrik

Coronary arteries

LM

LCX

LAD a LAD b

DG1

LAD a

LAD c

LAD

RCA

Images: Reija Västrik

Our institution protocol

• FOV: chest and upper abdomen, ECG-gated study

• Patient selection: – Cardiology consultation mandatory

– Pretest probability of coronary artery disease should be low or intermediate!!!

– ECG: normal or nonspecific changes

– Cardiac enzymes negative

– Normal kidney function (GFR > 45)

– Physician administers beta-blockers (iv metoprolol, ideal heart rate 60-70/min)

– Nitroglycerin to ensure coronary vasodilatation

– Patient has to co-operate

• Structured report

• 1. AORTA AND BRANCHES

• 1.1 Dissection or intramural hematoma YES/NO KYLLÄ/EI

Dissection type (A or B proximal or distal to left arteria subclavia)

• 1.2 Aneurysm YES/NO KYLLÄ/EI

Aneurysm description (localization and dimensions)

• 1.3 Aortic wall abnormalities (calcification, thrombus) YES/NO KYLLÄ/EI

• 1.4 Supra-aortic and visceral aortic branches

(patency, proximal stenosis, dissection) YES/NO

• 1.5 Aortic dimension sinus valsalva mm

sinotubulare junction mm ascending aorta mm aortic arch mm descending thoracal aorta upper part mm descending thoracal aorta lower part mm abdominal aorta suprarenal mm abdominal aorta infrarenal mm

Meilahti structured mTRO report

2.PULMONARY ARTERIES AND LUNG PARENCHYME

2.1 Pulmonary embolism YES/NO

location

2.2 Right ventricular dilatation YES/NO

2.3 Lung parenchyme YES/NO

2.4 Pleural abnormalities YES/NO

3. CORONARY ARTERIES AND HEART 3.1 Proximal coronary arteries normal/atherosclerotic /total occlusion 3.1.1 LM 3.1.2 LAD 3.1.3 LCX 3.1.4 RCA

3.2. Heart 3.2.1 Thrombus YES/NO 3.2.2 Valve calcifications YES/NO location 3.2.3 Pericardium, effusion/calcification YES/NO

4. UPPER ABDOMEN Short description of significant findings 5. SUMMARY

Coronary arteries

Borderline RCAa-stenosis 50-70%

Non-significant stenosis < 50% LAD a and b Normal left coronary artery

Normal right coronary artery

Our patients from February 2016 until April 2017

• Altogether 20 patients since 02/16

• Image quality diagnostic in every mTRO

• Most artefacts in coronary arteries, especially RCAb region (as in coronary CTA )

• Effective radiation dose 7,8 mSv

– Whole body CT ja aortic CTA 8 mSV

– Pulmonary artery CTA 3 mSv

– Coronary CTA 2 mSv

– Head CT native 9 mSV

– Head CT native and with contrast media 20 mSv

Our patients: findings

Patients (no) Findings

9 Normal or not explaining symptoms

4 Suspicion of significant coronary stenosis: in invasive angiography non-significant lesions

1 Cholecystitis

1 Hernia of Morgagni

1 Perimyocarditis

1 Decompensated heart failure

1 Lung fibrosis and suspicion of significant coronary stenosis: in invasive angiography non-significant lesions

1 RCA venous bypass graft occlusion

1 Type A aortic dissection, lung infection and decompensated heart failure

Case 1

• Female 30 yo

• Perimembranotic ventricular septal defect operated at the age of 10 months

• Excellent result, no follow-up in adulthood

• Healthy, no regular medications

• Pregnant G1P0, 40 weeks

• Weeks 40+4 upper abdominal pain, radiating to left shoulder, inhaling accelerates pain

• Nausea, lower limb swelling for 2 weeks

• Obstetrician: No gynecological reason, not in labour

• Stable hemodynamics, normotension, SpO2 97%

• ECG: normal

• U-prot ++

• TnT 118

• Mild leucosytosis, mildly elevated CRP 13

• ECHO: Normal LV function, no wall motion abnormalities. Valves normal. No signs of elevated pulmonary pressure or right ventricular dilatation

• Lower limb ultrasound: No DVT, upper abdomen ultrasound normal

• Pre-eclampsia? Coronary / aortic dissection? Pulmonary embolism?

Case 1

left ventricle

Herniated small intestine pericardium Herniated small intestine

aorta

Left ventricle

Images: Reija Västrik

• Diagnosis: Enstrangled hernia of Morgagni without ischemia

• operation ja c-section April 12th, home four days later on April 16th

defect in anterior diaphragm

Case 1

– Aortic dissection aortic CTA

– Acute coronary syndrome coronary angiogram

– Pulmonary embolism pulmonary artery CT

– Abdominal pain abdominal US/CT/MRI

– Atypical symptoms – I have no idea… mTRO CTA?

TRO: My take home message Patient selection! Patient selection! Patient selection!

When used wisely: • shortens hospital stay • less imaging studies,

radiation and contrast media

Not so wisely

• more radiation and more contrast media

• More incidental findings

Experienced clinician is mandatory…

Thank you!!!