Lecture Coronary CTA Cardiology Grand Rounds

  • “ Clinical Applications of Coronary CT  Computed Angiography:”.

  • Wednesday, April  27, 2022 Zoom meeting

  • Introduction

    • Good morning
    • Honor
      • Thanks
    • Ravin –
      • Go back along way
    • Nail on the Head
      • Two of the disciplines that have inspired me and made my career so rewarding
    • Heart
        • remarkable anatomy physiology
        • Has intrigue adventure drama and romance
        • Unlike the brain that just sits and thinks
        • the heart moves -it has rhythm it has sound
        • Shakespeare mentions it more than  1200 times
        • We celebrate it and what it means to people every year on Valentine’s day
        • My Teachers Go back a long way
          • Ongoing pursuit  to find the underlying principles that govern complexity
            • Parts
            • Size
            • Shape
            • Position
            • Character
            • Time
          • The Common Vein
          • Whichever technology is able to fulfill these elements wins the prize
          • And I believe it is CT(at least for the diagnosis of CAD) and  and I hope to convince you too
    • CT scan and I also go back a long way
    • It was advent of CT and its application that inspired me to
    • hang up my triple headed Tycos
Listen with Your Eyes foe a Diagnosis in the Heart and the Lungs
Ashley Davidoff thecommonvein.net Davidoff art #CXR #stethoscope heart0012-

 

Radiologist in a Dark Room
Acknowledgement Philips Medical Systems

At the time the perception of radiology was that
Working in a Dark Room
Subjectivity Dominated

But even in that world it gave  birth to people like Dotter, Seldinger and Judkins

However it was my  introduction to CT that sold Radiology to me

Nietsche – German philosopher

Believer in Perspectivism

Mother in Law Rosalie Fisher – Physicist

Nietzsche and the Truth

Looking at the the Pixel/Voxel from Many Angles

 

Scanner – 256 rows of detectors
8 centimeters of coverage, with the entire heart covered in two scans The rotation speed is 0.27 seconds (total .54 seconds with 120 kw of power.
Now available 640 rows and in .27 secs we scan the whole heart in one rotation
Ashley Davidoff thecommonvein.net

Gave numbers to the pixels

(just like the the 0 and 1 of computer science)

Enabled Objectivity – Ability to Accurately  Measure

Applying the Segmental Approach to Complex Structures

The Power of the Brick
It is Nothing by Itself  However the Whole is Only as Strong as the Weakest Brick
By Ashley Davidoff MD  TCV-0039  TheCommonVein.net
When the 37.2 trillion cells in the human body connect and organize, they create a spark of life housed in the body and gifted with a mind.  By Ashley Davidoff MD
TCV-0040  TheCommonVein.net

So for example looking at these liver cells

Cell Size 10 to 100 µm

And most of the time in clinical practice we use subjectivity

Subjective Evaluation of Character
Ashley Davidoff MD
thecommonvein.net
#subjectivity#Davidoff art #principles#character #diagnosis
character-0003
and on that basis we give the structure under evaluation

 

In the world of digital technology the cell = the pixel/voxel = about 1mm

The pixel  has a number embedded within it

Digital Information
Once we have data in pixel form we can manipulate the data and this is the strength of digital acquisition
Ashley Davidoff MD
thecommonvein.net

This methodology is therefore able to provide objectivity,  enabled by better measurement provided by  better tools (computer algorithms)

 

Subjectivity vs Objectivity in Science and Medicine
Ashley Davidoff MD
thecommonvein.net

CT Principles

Familiar to all is the Hounsfield Number relating to  the density
Density of Body Tissues Based on Hounsfield Units .  The human observer can perceive around 900 shades of gray.
Ashley Davidoff MD thecommonvein.net

Blooming Artifact

Blooming Artifact
The small calcified plaque in the top left image is an artistic version of the reality – calcified plaque that does not impinge on the lumen. The top right image is a CT in the ideal world recreated within the grid of pixels (voxels in 3D) The calcified plaque (white arrow) which shares a voxel space with the blood in the lumen) remains distinct and true to its size, demonstrating true lack of impingement on the lumen
The bottom row in gray scale shows what happens in a CT scan. The bottom left image shows what the CT would look like ie impingement by the plaque on the lumen. The bottom right explains the blooming artifact. The calcium of very high density (about 500HU) shares the voxel space with the blood which is soft tissue density (about 50 HU) and so the net density is about 450 HU. The voxel does not therefore reflect a true density and the lesion therefore appears to impinge on the lumen when, in actuality it does not. This is called the blooming artifact
Ashley Davidoff MD thecommonvein.net

At the Vessel Level

  • Coronary Artery
    • diameter 3-4mm
    • wall thickness ranges from  0.55 to 1.0 m
    • intima and adventitia.2mm – .3mm
    • … and the vessels is moving
Parts of the arterial wall We can resolve a pixel that is about 1mm in size.  Key questions in imaging are the size shape position and character of the arteries. Perfusion under rest and stress situations are also key considerations
Ashley Davidoff MD  thecommonvein.net

Subjectivity

 

96H

Consensus in the Trials

CTA Sensitivity and Specificity
Montalescol et al
EHJ 2013
  • However over over the last 10 years or so we have developed new tools that are able to enhance and better use the   information within the voxels  which are
  • readily applied because of the innate and sound basis of the digital acquisition of the information
  • Advances include
      • improved resolution
      • reduced radiation
      • faster times of acquisition
      • computational algorithms that are able to
        • infer function from structure (FFR CT )
        • methodology to characterize the tissues in the arterial wall

using  the digital information inside the voxels

The New Tools – “Game Changers”, “Paradigm  Shift”

  • Faster Acquisition –
    • 256 to 320- 640 detectors
      • 640-slice CT scanner can image the entire heart in less than one third of a second
    • 640 slice CT scanner uses 80% less radiation
  • Computerized Algorithms and AI
Current State of the Art
One Stop Shop – Calcium score, Coronary CTA, FFR CT, CT Perfusion, and Tissue Characterization

Calcium Score and Coronary CTA

Fractional flow reserve derived from CT – FFR CT

  • Normal  = 1.0
  • Abnormal <0.75-0.80
    • generally considered to be associated with myocardial ischemia

Diagnostic and Interventional Cardiology
https://www.dicardiology.com/article/study-demonstrates-accuracy-noninvasive-ct-ffr-evaluating-cad-patients

CT Perfusion

CT Perfusion

Plaque Characterization

Bittner D et al Coronary Computed Tomography Angiography–Specific Definitions of High-Risk Plaque Features Improve Detection of Acute Coronary Syndrome
Results From the ROMICAT II Trial
Circulation Cardiovascular Imaging Vol 11 No.8 Coronary

  • What we have learned is that we should approach
    • Chest Pain – like we approach
    • OA
    • ie as a mostly a chronic illness
  • We must approach Acute MI for its sneak attack methodologies
    • high suspicion for a hidden enemy
    • like pathological fracture

Understanding of atherosclerosis

History of Atherosclerosis

Serpiginous Splenic Artery – Da Vinci
This is a drawing of the “meseraic vessels” – presumably the celiac axis. Da Vinci was able to interview and perform an autopsy on a centenarian. He describes the desiccated and tortuos state of the vessels of this patient accurately depicting the atherosclerotic process. He describes the narrowed lumen and the consequences of poor blood flow.The translation of da Vinci’s text accompanying this one inch image is remarkably insightful and pioneering. (see atherosclerosis hisrorical da Vinci) 13045b

“….acquire so thick a covering that it contracts the passage of the blood .”

“I have found there stones in the vessels”

“The tunics of the vessels behave in man as in oranges, in which the peel thickens and the pulp diminishes the older they become. And if you say that it is the thickened blood which does not flow through the vessels, this is not true, for the blood does not thicken in the vessels because it continually dies and is renewed.”

Atherosclerosis

This is a post mortem specimen of the aorta of a patient with pulmonary atresia and bronchial collaterals. Overlaid in red are the enlarged orifices of the origins of the bronchial arteries. In yellow is the entrance of the PDA (patent ductus arteriosus) to the aorta Note in addition the normal appearing shiny appearance of the neonatal intima.
Ashley Davidoff MD
32628c
#aorta #normal intima#intima
This image shows three pathological specimens of the aorta. In the first image minimally raised fatty streaks are noted (a). In image (b), the fibrous capsule causes raised fibrofatty nodules, while in (c), there has been rupture of the plaques, with friable atheromatous plaques abound. The process is no different in the coronary arteries.
Courtesy: Henri Cuenoid, M.D.

Atherosclerosis

Atherosclerosis starts as a fatty infiltration in the intimal and subintimal layer progressing in size stimulating the formation of fibrous tissue to create the so called fibrofatty plaque. Dystrophic calcification results
Ashley Davidoff MD
thecommonvein.net
As the plaque grows , either as a fibrofatty plaque or a calcified plaque or a mixture and it slowly encroaches on the lumen causing progresive narrowing of the vessel and results in time wit decreased perfusion
Ashley Davidoff MD
thecommonvein.net

The Fatty Plaque with thin cap and neovascularity is a land mine waiting to explode

The Vulnerable Plaque

Plaque Rupture
This diagram shows denudation of the endothelial layer with exposure and rupture of the contents of the atherosclerotic plaque in volcanic fashion into the lumen. This event is catastrophic and can result in acute thrombosis and may even be a fatal event. 33801d Courtesy Ashley Davidoff MD. code heart artery atherosclerosis atheroma vulnerable plaque drawing Davidoff art
Ashley Davidoff
thecommonvein.net

 

Thrombus in LAD
The above image of this cardiac catheterization shows a coned down left anterior oblique (LAO) projection of the LAD in a patient with acute thrombosis of the left anterior descending artery. In the lower image, the thrombus in the artery is overlaid in maroon.

 

 

Vulnerable Plaque and Complications
This image consists of (a) a longitudinal section through the coronary artery showing calcified plaque (white) and a fibrofatty plaque (yellow) with about a 50% stenosis. Vulnerability is considered with features of a thin fibrous cap, and a density of less than 30HU. The associated CT shows a low density plaque measuring between 22 and 32HU. Image b shows a focal spotty calcification within the fibrofatty plaque and an associated CT confirm a punctate calcification within the plaque which is another sign of the vulnerable plaque. Image c shows positive remodeling of the wall defines as an outer vessel diameter that is 10% larger than the diameter of the vessel just proximal and distal to the disease. Image d shows intraplaque hemorrhage due to the neovascularity of the vasa vasorum, image e shows plaque ulceration and image e shows thrombosis.
Ashley Davidoff thecommonvein.net

CT and Vulnerable Plaque – IVUS

Abdelrahman et JACC 2020

Abdelrahman et JACC 2020

Patient with Psoriasis, Atherosclerotic Disease Before and After Biologic Therapy


Abdelrahman et JACC 2020

 

Conclusion and Summary

  • I saw it for myself in Washington DC
  • It is definitely on their minds
  • Saw the writing on the walls (floor) of the
  • National Airport
  • Between Concourse B and C

Digital Make Up of the Coronary Artery

The Arterial Wall
Ashley Davidoff MD
thecommonvein.net
Mosaic on the floor of the Ronald Reagan National Airport in Washington

 

Concern for Lipid Infiltration into the Vessels

Concern for the Vulnerable

Focus to Treat and Help the Vulnerable Before it was too Late

 

Phospholipid Infiltration Build Up of Unhealthy Elements in the Society and Attention to the Vulnerable
Ashley Davidoff MD
thecommonvein.net
Mosaic on the floor of the Ronald Reagan National Airport in Washington

 

Advancing Computerised Evaluation of Flow Dynamics

Remembering  the Role of  Shear Stress

 

Computational Flow Dynamics and Shear Stress
Ashley Davidoff MD
thecommonvein.net
Mosaic on the floor of the Ronald Reagan National Airport in Washington

 

Concern for Shortfalls of Energy Delivery

Attention to Myocardial Perfusion

Myocardial Perfusion
Ashley Davidoff MD
thecommonvein.net
Mosaic on the floor of the Ronald Reagan National Airport in Washington

 

Approaching a Problem from Many Angles to get to the Truth

Approach to the Truth
Looking at the Element in Hand from as MAny Angles in Order to Come to the Truth
Ashley Davidoff MD
thecommonvein.net
Mosaic on the floor of the Ronald Reagan National Airport in Washington

 

 

    • Evaluation of stable chest pain often
      • requires diagnostic testing with the
      • goals of
        • detecting coronary artery disease (CAD) and
          • non obstructive
          • obstructive
        • assessing the risk of a
          • future major adverse cardiovascular event (MACE),
            • death,
            • myocardial infarction, or
            • unstable angina

  • Background and History

  • see web image 258 Anatomic imaging is very sensitive as to who may have a CV event down the line Functional image not so much or who may nothave an event

  •  Indications

    • First Line Study  (Narula J, et al 2021 Expert Consensus Document)

    • Chest pain no known CAD presenting with
    • Chest Pain with known CAD presenting with
    • Unclear or inconclusive stress test results.
    • When considering evaluation for revascularization strategies
        •  ISCHEMIA Trial
    • Selected asymptomatic high risk individuals
    • Rarely appropriate
      • very low risk symptomatic patients, e.g., <40 years of age with non-cardiac symptoms (chest wall pain, pleuritic chest
        pain)
      • low- and intermediate risk asymptomatic patients
  • Risk Stratification

  • Contraindications

    • Renal
    • Excessive Coronary Calcification
    • Relative
      •  patient’s heart rate,
      • body weight, or
      • ability to perform a breath-hold,
      • contrast or problems with
      • vascular access (which may make invasive angiography more prone to complication)–

  • Advantages

    • high negative predictive value
    • Provides high-definition 3-D images of the arteries feeding the heart and blockages at the earliest stages when they can be treated most effectively
    • Most accurate noninvasive diagnostic test for coronary artery disease
    • Measures both calcified and noncalcified plaques. Noncalcified plaques are more prone to rupture and cause heart attacks than calcified plaques. By assessing both types of plaque, coronary CTA analyzes your risk for a heart attack.
    • Monitor the effectiveness of therapy since noncalcified plaques may shrink with effective treatment
    • cross-sectional nature permits visualization not only of the contrast-enhanced coronary artery lumen, but also of the vessel wall (if image quality is adequate). In this way, atherosclerotic plaque can become visible, which is undetectable in the invasive coronary angiogram

  • Disadvantages

    • lacking in
      • specificity ie lot of false positives
      • positive predictive accuracy, ie lot of false positives
        • which has led to the development of value added CTA strategies like fractional flow reserve derived from CT and CT perfusion.
    • Radiation
      • Goal median <5milliSieverts (15 5-10 years ago)
      • NM 10-15 milliSieverst
    •  Limited temporal resolution can reduce image quality, especially if heart rates are above 60 beats per minute (bpm)
    • Since data acquired over several heartbeats are necessary to acquire a complete data set, coronary CTA is not reliably possible in patients with arrhythmias (scanner design concepts with ≥256 slices may help overcome this limitation).
    • analysis was limited to segments of ≥1.5 mm in diameter.
    • Also, there is a tendency to overestimate the degree of stenosis in CT as compared with the invasive angiogram,
    • extensive calcifications can render image interpretation impossible.
    • In patients with a very low pretest likelihood, the false-positive rate may be too high,
    • patients with a very high pretest likelihood, sensitivity may not be sufficiently high.
      • patients with a high pretest likelihood of disease, performing an invasive, catheter-based coronary angiogram will often be much more appropriate because it offers the option of immediate treatment.

  • Aim

  • Method

  • Links and References

  • TCV
  • TCV
  • Literature
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    • Stone K.E.  History of Coronary CTA
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    • Meinel, F et al Radiation Risks From Cardiovascular Imaging Tests Circulation. 2014;130:442-445  PDF file