Journal of Cardiovascular Computed Tomography

Journal introduction

Allen J. Taylor — 2010-06-07

We live in an era of comparative medicine, from hospitals to clinicians, drugs, or technology. Whether today's “gold standard” will remain so is subject to challenge, and at a minimum the present standards form the comparative backdrop on which new evolutionary changes are developed. As a new and evolving technology, cardiac CT has been no stranger to such comparative evaluations for routine applications such as coronary CT angiography for evaluation of coronary atherosclerosis. Beyond routine CT angiography, this issue of the Journal provides examples of the evolution of the technology with cardiac CT considered for the evaluation of coronary artery anomalies relative to invasive coronary angiography and for the assessment of myocardial infarction. Each step represents a small advance in the evolution of a technology, incrementally expanding our knowledge base, and understanding of the potential, optimum approach, and clinical application of cardiac CT.

Computed tomography of septal defects

Prabhakar Rajiah, Jeffrey P. Kanne — 2010-05-31

Abstract: Septal defects are common congenital cardiac anomalies that may present in adulthood. Although echocardiography and magnetic resonance imaging are most frequently used to assess for and evaluate septal defects, multidetector computed tomography (CT), with its high spatial and temporal resolutions, multiplanar reconstruction capabilities, and wide field of view, is an excellent tool for detection and characterization of septal defects and for identification of associated anomalies of the heart and pulmonary vasculature. Knowledge of the CT appearances of septal defects and their respective associated abnormalities is critical for accurate reporting as well as for providing information for planning of surgical or percutaneous therapy. In this pictorial review, the CT appearances of various atrial and ventricular septal defects and associated shunts are described and illustrated.

Role of MDCT coronary angiography in the evaluation of septal vs interarterial course of anomalous left coronary arteries

2010-04-12

Background: Conventional coronary angiography (CCA) may be inaccurate to distinguish between interarterial and septal subtypes of anomalous left coronary arteries (CAs).Objective: We compared the classification of anomalous left CA arising from the right sinus of Valsalva (RSV) or right CA on the basis of multidetector computed tomography coronary angiography (MDCTCA) with the classification derived from CCA.Methods: A retrospective review of 6000 consecutive electrocardiographic-gated MDCTCAs identified 15 cases of anomalous left main or left anterior descending CA arising from the RSV or right CA coursing between the aorta and the main pulmonary artery. On the basis of MDCTCA findings, the proximal course of each vessel was classified into 3 subtypes: 1, interarterial; 2, septal; and 3, mixed. CCA was reviewed in 5 cases (33%) and classified according to traditional criteria. When CCA images were not available, 3-dimensional volume-rendered reconstructions were used to simulate CCA.Results: On the basis of MDCTCA, subtypes were distributed as type 1 (n = 2), type 2 (n = 4), and type 3 (n = 8). One case could not be classified into any of these subtypes and was classified as type 4, right ventricular infundibulum (RVI). Applying CCA criteria, 2 cases would have been classified as interarterial and 14 as septal without appreciation of the mixed or RVI subtypes.Conclusions: Classification of anomalous left CAs into either septal or interarterial may be too simplistic. There is an anatomic spectrum of anomalous left CAs detected by MDCTCA that challenges the traditional classification based on CCA.

Left coronary artery from the right coronary sinus: What can CT angiography tell us?

Paolo Angelini, Benjamin Cheong — 2010-05-31

Multidetector CT angiography (MDCTA) provides an accurate modality for the detection of coronary artery anomalies among which those involving ectopic origin of a coronary artery from the contralateral coronary cusp are of particular interest because of their associated morbidity and mortality. In this issue of the Journal, Torres et al describe the CT anatomic features of 15 cases of ectopic left coronary artery originating from the right sinus of Valsalva. Although traditional anatomic risk stratification has focused on the detection of cases in which the left coronary artery courses interarterially (between the aorta and pulmonary artery), the authors describe, not surprisingly, that these anomalies exist along an anatomic spectrum that can potentially be refined with the use of CT imaging. Although based on a small number of observations because of the rarity of this anomaly, this article serves as an opportunity to highlight a number of issues coming to the forefront within imaging of coronary artery anomalies in the present era of axial CT imaging. These include redefining their prevalence, the prognostic implications of imaging findings, insights into the pathophysiology of anomalies, and optimal imaging approaches.

Comparison of postprocessing techniques for the detection of perfusion defects by cardiac computed tomography in patients presenting with acute ST-segment elevation myocardial infarction

2010-04-12

Background: Despite rapid advances in cardiac computed tomography (CT), a strategy for optimal visualization of perfusion abnormalities on CT has yet to be validated.Objective: We evaluated the performance of several postprocessing techniques of source data sets to detect and characterize perfusion defects in acute myocardial infarctions with cardiac CT.Methods: Twenty-one subjects (18 men; 60 ± 13 years) that were successfully treated with percutaneous coronary intervention for ST-segment myocardial infarction underwent 64-slice cardiac CT and 1.5 Tesla cardiac magnetic resonance imaging (MRI) scans after revascularization. Delayed enhancement MR images were analyzed to identify the location of infarcted myocardium. Contiguous short-axis images of the left ventricular myocardium were created from the CT source images with 0.75-mm multiplanar reconstruction (MPR), 5-mm MPR, 5-mm maximal intensity projection (MIP), and 5-mm minimum intensity projection (MinIP) techniques. Segments already confirmed to contain infarction by MRI were then evaluated qualitatively and quantitatively with CT.Results: Overall, 143 myocardial segments were analyzed. On qualitative analysis, the MinIP and thick MPR techniques had greater visibility and definition than the thin MPR and MIP techniques (P < 0.001). On quantitative analysis, the absolute difference in Hounsfield unit attenuation between normal and infarcted segments was significantly greater for the MinIP (65.4 Hounsfield unit [HU]) and thin MPR (61.2 HU) techniques. However, the relative difference in Hounsfield unit attenuation was significantly greatest for the MinIP technique alone (95%; P < 0.001). Contrast to noise was greatest for the MinIP (4.2) and thick MPR (4.1) techniques (P < 0.001).Conclusion: The results of our current investigation found that MinIP and thick MPR detected infarcted myocardium with greater visibility and definition than MIP and thin MPR.

Cardiac computed tomography for prediction of myocardial viability after reperfused acute myocardial infarction

2010-04-21

Background: Perfusion defects (PDs) detected with cardiac magnetic resonance (CMR) imaging predict the functional recovery of myocardial function after acute myocardial infarction.Objective: We evaluated the ability of cardiac computed tomography (CCT) to predict the recovery of regional left ventricular (LV) systolic function after ST elevation myocardial infarction (STEMI).Methods: Seventeen patients (mean age, 60 ± 10 years) presenting with STEMI were prospectively studied. Each patient underwent CCT and CMR at baseline and after an average of 6 months. Areas of PD were quantified. Segmental LV systolic function was semiquantitatively assessed by CMR. An improvement at 6 months by ≥1 category in the regional wall motion score was considered LV recovery.Results: Coronary artery revascularization was successfully performed with postprocedural TIMI 3 flow in 16 cases. On CCT assessment, 107 of 289 segments (37%) had some degree of PD. On follow-up, segments with <25% PD at baseline had no worsening of wall motion. In segments with >75% PD, 89% (9 of 11) showed akinesis or worsening of wall motion. The odds ratio for improvement in segmental wall motion with increasing PD category was 0.63 (95% CI, 0.42–0.97; P = 0.035). The degree of PD on CT predicted LV recovery at follow-up (P < 0.0001).Conclusions: The transmural extent of myocardial infarction as detected and quantified with CCT predicts the recovery of regional systolic LV function after revascularization for acute STEMI.

CT imaging of myocardial infarction: Time for another step forward

Andreas H. Mahnken — 2010-05-31

Cardiac computed tomography (CCT) is the most rapidly evolving imaging modality for the image-based assessment of cardiac structure. Its potential for assessing the coronary arteries has been extensively evaluated, and it is an accepted technique for detecting coronary artery disease in patients with intermediate pretest probability or uninterpretable stress test. Its value for assessing the left ventricular (LV) myocardium in the presence of myocardial infarction (MI) is generally considered uncertain. Currently, a variety of factors converge, potentially enabling CCT to become a relevant technique for assessing the hemodynamic relevance of coronary artery stenoses and the extent of MI. These developments will contribute to make CCT a pivotal cornerstone in the management of patients with coronary heart disease (CHD).

Calcified right intraventricular thrombus in a patient with systemic lupus erythematous and antiphospholipid syndrome

Márcio Sommer Bittencourt, Martin Seltmann, Gerd Muschiol, Stephan Achenbach — 2010-05-31

Abstract: A 37-year-old patient with known systemic lupus erythematous, antiphospholipid syndrome and previous pulmonary embolism presented with non-ST elevation myocardial infarction while on adequate anticoagulation therapy. The patient was further evaluated with cardiac computed tomography. A small diagonal branch occlusion was the only coronary lesion present. A partially calcified right ventricular thrombus was incidentally found. Because of the small vessel size, cardiac catheterization was deemed unnecessary, and the patient was discharged with adjustment of immunosuppressive therapy and anticoagulation.

Coronary arterial microfistulae: A CT coronary angiography perspective

Grant R. Mitchell, Gareth Morgan-Hughes, Carl Roobottom — 2010-06-02

Abstract: Coronary arterial microfistulae are abnormal connections between one or multiple coronary arteries and any cardiac chamber, vein, or thoracic vessel. They comprise a subsection of coronary fistulas where the abnormal connections are diffuse, as opposed to the larger, more common single vessel varieties. Most of these anomalies are detected incidentally on catheter angiography; however, we present this anomaly as a case report from the perspective of CT coronary angiography.

Evaluation of cor triatriatum dexter with use of 64-slice multidetector computed tomography

2010-06-02

Abstract: Cor triatriatum dexter, a rare condition in which the right atrium is divided by an anomalous membrane, is shown with cardiac CT, magnetic resonance imaging and direct surgical visualization.

Giant left ventricular pseudoaneurysm

Sumi Prakash, Nadish Garg, Gong-Yuan Xie, Kevin C. Dellsperger — 2010-05-31

Abstract: Left ventricular (LV) pseudoaneurysm (PS) is an uncommon, often fatal complication associated with myocardial infarction, cardiothoracic surgery, trauma, and, rarely, infective endocarditis. A 28-year-old man with prior history of bioprosthetic mitral valve replacement presented with congestive heart failure and bacteremia with Abiotrophia granulitica. Transesophageal echocardiogram showed bioprosthesis dysfunction, large vegetations, mitral regurgitation, and probable PS. Cardiac and chest CT confirmed a PS communicating with the left ventricle Patient had pulseless electrical activity and died. Autopsy showed a giant PS with layered thrombus and pseudo-endothelialized cavity. Our case highlights the importance of multimodality imaging as an important tool in management of PS.

Atlas of Cardiovascular Computed Tomography

Tiffany Priester — 2010-06-07

The Atlas of Cardiovascular Computed Tomography edited by Allen Taylor is a new title in a series of companion texts to Braunwald's Heart Disease. This insightful and practical atlas spans 278 pages in 22 chapters. More than 30 authors, each an expert in their field, contributed to this book. As an atlas, this title contains extensive use of images with more than 580 illustrations and pictures that address a wide range of topics. As a bonus, purchase of this text includes an activation code to access the full text and all the images online through Expert Consult.

Society News

2010-05-31

President's Page: Prospective and retrospective preeminence: What is right about coronary CT

Jack A. Ziffer — 2010-05-31

Edward Teller, considered the father of the hydrogen bomb and cofounder of Lawrence Livermore National Laboratory, remarked, “No endeavor that is worthwhile is simple in prospect. If it is right, it will be simple in retrospect.”

2010-07-01