Camilla Barbiani

Non invasive cardiac vein mapping: Role of multislice CT coronary angiography

PURPOSE Coronary venous anatomy is of primary importance when implanting a cardiac resynchronization therapy device, besides, the coronary sinus can be differently enlarged depending on chronic heart failure. The aim of this study is to evaluate the usefulness of Coronary CTA in describing the coronary venous tree and in particular the coronary sinus and detecting main venous system variants. MATERIALS AND METHODS 301 consecutive patients (196 ♂, mean age 63.74 years) studied for coronary artery disease with 64 slice Coronary CTA were retrospectively examined. The acquisition protocol was the standard acquisition one used for coronary artery evaluation but the cardiac venous system were visualized. The cardiac venous system was depicted using 3D, MPR, cMPR and MIP post-processing reconstructions on an off-line workstation. For each patient image quality, presence and caliber of the coronary sinus (CS), great cardiac vein (GCV), middle vein (MV), anterior interventricular vein (AIV), lateral cardiac vein (LCV), posterior cardiac vein (PCV), small cardiac vein (SCV) and presence of variant of the normal anatomy were examined and recorded. RESULTS CS, GCV, MV and AIV were visualized in 100% of the cases. The LCV was visualized in 255/301 (84%) patients, the PCV in 248/301 (83%) patients and the SCV in 69/301 (23%) patients. Mean diameter of the CS was 8.7 mm in 276/301 (91.7%) patients without chronic heart failure and 9.93 mm in 25/301 (8.3%) patients with chronic heart failure. CONCLUSIONS Coronary CTA allows non invasive mapping of the cardiac venous system and may represent a useful presurgical tool for biventricular pacemaker devices implantation.

Virtual autopsy using multislice computed tomography in forensic medical diagnosis of drowning

PurposeThis study evaluated the usefulness of multidetector computed tomography (MDCT) in the postmortem diagnosis of death by drowning in fresh water by measuring the difference of blood density within the cardiac chambers.Materials and methodsTwenty-two corpses including six cases of fresh-water drowning (group A) and 16 deaths by other causes (group B), among which were also different forms of mechanical asphyxia other than drowning, underwent MDCT and conventional autopsy. Blood density within the right and left heart chambers, the aorta and the pulmonary trunk was measured and values compared between groups and within each group between heart chambers.ResultsBlood density in all cardiac chambers was lower in group A than in group B. The difference was statistically significant within the left atrium and ventricle and was significantly lower in the left than in the right heart chambers in group A only.ConclusionsMDCT, together with conventional autopsy, may contribute to the diagnosis of drowning, by measuring blood density in the heart chambers.RiassuntoObiettivoValutare se l’impiego della tomografia computerizzata multistrato (TCMS) possa essere d’aiuto nella diagnosi di morte per annegamento in acqua dolce tramite misura della differenza di concentrazione ematica all’interno delle camere cardiache.Materiali e metodiSono stati sottoposti a TCMS ed esame autoptico convenzionale 22 cadaveri, di cui 6 morti per annegamento in acqua dolce (gruppo A) e 16 per altre cause (gruppo B), tra le quali erano presenti anche asfissie meccaniche diverse dall’annegamento. è stata misurata la densità del sangue all’interno delle camere cardiache di destra e sinistra, dell’aorta e del tronco polmonare e confrontati i valori tra i due gruppi e all’interno di ogni gruppo tra le camere cardiache.RisultatiLa densità ematica all’interno di tutte le camere cardiache è risultata inferiore nel gruppo A rispetto al gruppo B. La differenza è risultata statisticamente significativa all’interno di atrio e ventricolo di sinistra. La densità ematica è risultata significativamente inferiore nelle camere cardiache di sinistra rispetto quelle di destra solo nel gruppo A.ConclusioniLa TCMS può essere impiegata per la misura della densità ematica nelle camere cardiache per la diagnosi di morte da annegamento in acqua dolce in ausilio all’esame autoptico convenzionale.

Coronary artery anatomy and variants

Variants and congenital anomalies of the coronary arteries are usually asymptomatic, but may present with severe chest pain or cardiac arrest. The introduction of multidetector CT coronary angiography (MDCT-CA) allows the detection of significant coronary artery stenosis. Improved performance with isotropic spatial resolution and higher temporal resolution provides a valid alternative to conventional coronary angiography (CCA) in many patients. MDCT-CA is now considered the ideal tool for three-dimensional visualization of the complex and tortuous anatomy of the coronary arteries. With multiplanar and volume-rendered reconstructions, MDCT-CA may even outperform CCA in determining the relative position of vessels, thus providing a better view of the coronary vascular anatomy. The purpose of this review is to describe the normal anatomy of the coronary arteries and their main variants based on MDCT-CA with appropriate reconstructions.

Normal anatomy and variants of the venous cardiac system in MDCT coronary angiography

Three separate venous systems drain the blood returning from the heart walls. These veins are characterised by remarkable variability in terms of frequency, size and course. The knowledge of cardiac venous anatomy is of primary importance during interventional cardiac procedures that require catheterisation of cardiac veins. Some anatomical variants may hinder or contraindicate access to target veins. Coronary angiography (CA) with multidetector computed tomography (MDCT-CA) and multiplanar reformations (MPR), maximum intensity projection (MIP) and 3D reconstructions provides noninvasive visualisation of normal cardiac veins and anatomical variants. The purpose of this pictorial review is to describe by MDCT-CA the anatomy and main variants of the cardiac venous system.RiassuntoIl sangue refluo dal cuore è raccolto da tre sistemi di vene caratterizzate da una notevole variabilità in termini di frequenza, calibro e decorso. Conoscere l’anatomia venosa cardiaca è importante in relazione a manovre di cardiologia interventistica che richiedono la cateterizzazione delle vene cardiache, dal momento che alcune varianti anatomiche possono ostacolare o controindicare l’accesso alle vene target. L’angiografia coronarica mediante tomografia computerizzata multistrato (TCMS) permette, tramite ricostruzioni 3D, ricostruzioni multiplanari (MPR), MPR curve e proiezioni di massima intensità (MIP), la visualizzazione dell’anatomia venosa cardiaca normale e delle sue varianti in modo non invasivo, fornendo una valida alternativa alla venografia retrograda. Lo scopo di questo pictorial consiste nella descrizione mediante immagini TCMS con ricostruzioni 3D dell’anatomia e delle principali varianti delle vene cardiache.

Role of MDCT coronary angiography in the clinical setting: economic implications.

PurposeThis study evaluated the incremental value and cost-effectiveness ratio of introducing coronary angiography (CA) with multidetector computed tomography (MDCT-CA) in the diagnostic management of patients with suspected coronary artery disease (CAD) compared with the traditional diagnostic workup.Material and methodsFive hundred and fifty consecutive patients who underwent MDCT-CA between January 2009 and June 2011 were considered. Patients with atypical chest pain and suspected obstructive CAD were directed to one of two diagnostic pathways: the traditional protocol (examination, stress test, CA) and the current protocol (examination, stress test, MDCT-CA, and CA, if necessary). The costs of each protocol and for the individual method were calculated. Based on the results, the cost-effectiveness ratio of the two diagnostic pathways was compared. A third, modified, diagnostic pathway has been proposed with its relative cost-effectiveness ratio (examination, MDCT-CA, stress test, and CA, if necessary).ResultsStress test vs. MDCT-CA had an accuracy of 66%, a sensitivity and specificity of 21% and 87%, respectively, and a positive (PPV) and negative (NPV) predictive value of 40% and 70%, respectively. Comparison between conventional CA (CCA) and MDCT-CA showed a sensitivity and specificity of 92% and 89%, respectively, a PPV and NPV of 89%, and an accuracy of 92%. The traditional protocol has higher costs than the second protocol: 1,645 euro against 322 euro (mean), but it shows a better cost-effectiveness ratio. The new proposed protocol has lower costs, mean 261 euro, with a better costeffectiveness ratio than the traditional protocol.ConclusionsThe diagnostic protocol for patients with suspected CAD has been modified by the introduction of MDCT-CA. Our study confirms the greater diagnostic performance of MDCT-CA compared with stress test and its similar accuracy to CCA. The use of MDCT-CA to select patients for CCA has a favourable cost-effectiveness profile.RiassuntoObiettivoScopo del presente lavoro è stato valutare il valore incrementale dell’introduzione della angiografia coronarica mediante tomografia computerizzata multistrato (AC-TCMS) nella gestione diagnostica del paziente con sospetta malattia coronarica (CAD) rispetto al tradizionale workup diagnostico in termini di rapporto costo/efficacia.Materiali e metodiSono stati considerati 550 pazienti consecutivi sottoposti ad AC-TCMS tra gennaio 2009 e giugno 2011. Sono stati considerati due percorsi diagnostici per pazienti con dolore toracico atipico e sospetta coronaropatia ostruttiva: il protocollo tradizionale (visita, stress test, coronarografia) e il protocollo attuale, (visita, stress test, AC-TCMS ed eventuale coronarografia). è stato calcolato il costo di ogni protocollo come la somma dei costi delle singole metodiche. Sulla base dei risultati i due percorsi diagnostici sono stati confrontati dal punto di vista del rapporto costo/efficacia. è stato proposto un terzo percorso diagnostico modificato con relativo rapporto costo/efficacia (visita, AC-TCMS, stress test, eventuale coronarografia).RisultatiLo stress test nei confronti dell’AC-TCMS ha attenuto valori di accuratezza del 66% con sensibilità e specificità del 21% e 87% e valore predittivo positivo (VPP) e valore predittivo negativo (VPN) di 40% e 70%. Il confronto tra ACC e AC-TCMS ha rilevato una sensibilità e specificità pari a 92% e 89%, un VPP e VPN pari a 89% per un’accuratezza complessiva del 92%. Il protocollo tradizionale è risultato avere costi più elevati rispetto a quello modificato dalla AC-TCMS, 1645 euro contro 322 euro (media), ma dimostra un miglior rapporto costo/ efficacia. Il nuovo protocollo proposto risulta avere costi minori, 261 euro in media, con un miglior rapporto costo/ efficacia, rispetto al protocollo tradizionale.ConclusioniIl protocollo diagnostico di un paziente con sospetta CAD ha subito variazioni con l’introduzione dell’AC-TCMS. Il nostro studio conferma una maggior performance diagnostica dell’AC-TCMS nei confronti del test da sforzo ed un’accuratezza simile a quella della coronarografia. Dai nostri dati, l’utilizzazione di un protocollo che prevede l’AC-TCMS come spartiacque principale per i pazienti da inviare alla coronarografia, risulta vantaggioso in termini di costo e di efficacia diagnostica.

Learning curve in multidetector CT coronary angiography (MDCT-CA).

PurposeCoronary angiography using multidetector computed tomography (MDCT-CA) is a recent technique for the nonivasive study of coronary arteries. This study assessed the diagnostic accuracy of coronary artery stenosis evaluation obtained by three readers at different levels of training or at different points of the learning curve proposed by the international guidelines.Materials and methodsThree radiologists in training with different levels of experience in MDCT-CA scored 50 cases at various time points of the learning curve: baseline, 4 weeks, 8 weeks and 6 months. The trainee radiologists evaluated the degree of stenosis on each coronary segment, and overall accuracy was calculated on a per-segment, pervessel and per-patient basis.ResultsAll readers improved analysis accuracy per segment (range, 73–90%); sensitivity reached 45% per segment, 84% per vessel and 93% per patient; specificity was 99% per segment and vessel and 98% per patient. Positive and negative predictive values increased to 94% and 92%, respectively.ConclusionsAlthough all readers improved in diagnostic performance with growing experience with MDCT-CA, a longer training period may be necessary to achieve adequate levels of expertise in MDCT-CA to be able to perform as independent readers.RiassuntoObiettivoValutare l’accuratezza diagnostica nella stima di stenosi coronarica con l’angiografia coronarica mediante TCMS (AC-TCMS) ottenuta da tre lettori nei vari livelli di training proposti dalle linee guida internazionali come curva di apprendimento.Materiali e metodiTre lettori medici in formazione con esperienza in AC-TCMS differente hanno eseguito l’analisi sistematica delle AC-TCMS di 50 pazienti in diversi step della curva di apprendimento: iniziale, a 4 settimane, 8 settimane, 6 mesi. Per ogni segmento è stato valutato il grado di stenosi ed è stata calcolata l’accuratezza globale mediante analisi per segmento, vaso e paziente.RisultatiTutti i lettori hanno incrementato la loro accuratezza (range 73–90%) nell’analisi per segmento; la sensibilità con valori massimi per segmento pari a 45%, per vaso a 84% e per paziente a 93%; la specificità con valori massimi per l’analisi per segmento e vaso pari a 99% e per paziente pari a 98%. Anche i valori di predittività positiva e negativa sono incrementati raggiungendo valori rispettivamente pari a 94% e 92%.ConclusioniSebbene tutti i lettori abbiano migliorato la loro performance diagnostica aumentando la loro esperienza in AC-TCMS, può essere necessario un tempo più lungo per raggiungere un’esperienza adeguata in ACTCMS tale da consentire una valutazione indipendente.

Role of coronary angiography MDCT in the clinical setting: changes in diagnostic workup in the real world.

PurposeThe authors sought to evaluate the incremental value of introducing coronary angiography with multidetector computed tomography (MDCT-CA) compared with the conventional diagnostic workup in managing patients with suspected coronary artery disease (CAD) workup.Materials and methodsA total of 531 consecutive patients underwent MDCT-CA between April 2008 and August 2010. For each patient the pretest probability of CAD was obtained by using the Morise score as well as the diagnostic performance of the exercise test and of MDCT-CA, considering conventional coronary angiography (CCA) as the gold standard. Based on these results, we calculated the posttest likelihood of CAD after stress testing, comparing the incremental diagnostic value for each category of cardiovascular risk with data obtained with MDCT-CA. The conventional diagnostic workup (without MDCT-CA) was then compared with the modified workup (including MDCT-CA).ResultsThe diagnostic performance of the exercise test for identifying patients with significant lesions had a sensitivity and specificity of 20% and 88%, respectively, with positive (PPV) and negative (NPV) predictive value of 41% and 72%, respectively. Taking CA as the gold standard, MDCT-CA had 93% sensitivity, 89% specificity, 88% PPV and 93% NPV compared with CCA in evaluating significant stenoses in the per-patient analysis. The overall diagnostic accuracy of MDCT-CA was 91%. The exercise tests provided no significant incremental diagnostic value compared with cardiovascular history in patients with a low to intermediate risk. Comparison of the diagnostic accuracy of these protocols showed improved performance results for the modified protocol.ConclusionsMDCT-CA is the reference modality for the noninvasive exclusion of critical CAD. It provides a very high incremental diagnostic value compared with exercise testing in patients with a low to intermediate risk of CAD. The use of diagnostic protocols based on MDCT-CA ensures improved diagnostic performance compared with those involving conventional exercise electrocardiograms.RiassuntoObiettivoScopo del nostro lavoro è valutare il valore incrementale dell’introduzione della angiografia coronarica mediante tomografia assiale multistrato (AC-TCMS) nella gestione diagnostica del paziente con sospetta malattia coronarica (CAD) rispetto al tradizionale workup diagnostico.Materiali e metodiSono stati presi in considerazione 531 pazienti consecutivi sottoposti ad AC-TCMS tra marzo 2008 e agosto 2010. Per ogni paziente è stato calcolata la probabilità pre-test di CAD mediante Morise score e la performance diagnostica del cicloergometro e della ACTCMS considerando l’AC come standard di riferimento; Sulla base dei risultati è stata calcolata la probabilità post-test di CAD dopo stress test, confrontandone il valore diagnostico incrementale per ogni categoria di rischio cardiovascolare con i dati ottenuti dalla AC-TCMS. è stato confrontato il percorso diagnostico tradizionale senza ACTCMS, con quello modificato dall’introduzione dell’ACTCMS.RisultatiLa performance diagnostica dello stress test nella individuazione dei pazienti con lesioni significative ha dimostrato una sensibilità e specificità del 20% e 88% con valore predittivo positivo (VPP) e valore predittivo negativo (VPN) di 41% e 72%. Considerando come standard di riferimento la AC il confronto tra AC e ACTCMS nella valutazione di stenosi significative mediante analisi per paziente ha rilevato una sensibilità pari a 93%, una specificità pari a 89%, un VPP e VPN pari a 88 % e 93%. L’accuratezza diagnostica globale della metodica è risultata essere pari a 91%. Lo stress test ha dimostrato di non fornire un significativo valore diagnostico incrementale rispetto all’anamnesi cardiovascolare nei pazienti a basso-medio rischio. Il confronto tra l’accuratezza diagnostica dei protocolli ha dimostrato una migliore performance del protocollo che prevede l’introduzione dell’ACTCMS nei confronti del protocollo tradizionale.ConclusioniLa AC-TCMS è una metodica di riferimento non invasiva per l’esclusione di coronaropatia critica. Fornisce un valore diagnostico incrementale molto elevato rispetto allo stress test nei pazienti a basso-medio rischio. L’utilizzazione del protocollo diagnostico che prevede l’utilizzo dell’AC-TCMS garantisce una migliore perfomance diagnostica rispetto al protocollo tradizionale.

Compared analysis of two different software for iron overload quantification in cardiac MRI

Purpose: The justification and optimisation of medical imaging employing ionizing radiation have been intensely discussed in recent years, particularly for computed tomography (CT). A key point in this discussion is the estimation of patient dose, which commonly employs radiation output metrics developed for quality assurance and no patient specific information. Such patient dose estimates are of limited value, and more refined methods needs to be promoted and provided to the community. Methods and Materials: AAPM Task Group 246 was formed in 2013, and in a joint venture with EFOMP charged with summarizing present methodology and DICOM information available for estimating patient dose with computed tomography.Results: The Joint Report of AAPM Task Group 246 and EFOMP is a comprehensive resource for the clinical medical physicist. The possibilities of patient specific dosimetry from the Computed Tomography Dose Index (CTDIvol), to the Size-Specific Dose Estimates (SSDE) and advanced Monte Carlo methods are discussed together with available DICOM information, as well as practical examples on how patient dose estimates can be achieved. The report also summarizes important factors contributing to the uncertainty in patient dose estimates and gives examples of achievable confidence intervals.Conclusion: The SSDE and Monte Carlo methods can together with detailed scanner, examination and patient specific DICOM information offer refined estimates of patient dose for justification and optimisation of CT examinations. Given the present robustness of available methods AAPM Task Group 246 and EFOMP recommend that all reports of patient dose should be accompanied by estimates of the associated uncertainty.

Uncommon double fistula between sinus node arteries and right atrium in a patient with atypical chest pain.

The main coronary artery variants and anomalies are completely asymptomatic and are discovered incidentally or as they rise symptoms. Multidetector computed tomography coronary angiography represents an excellent technique for noninvasive assessment of the coronary tree mainly because of the multiplanar imaging modalities of computed tomography. Thin collimation permits to depict thin vessels such as the sinus node artery, as reported in this case. In this brief report, we describe a case of a rare anomaly of termination the coronaries, a double fistula between the sinus node artery, and the right atrium in a patient with atypical chest pain.

Artifacts in Cardiac CT

The reliability, simplicity and repeatability of the scan make CT a very interesting modality for noninvasive diagnostic imaging of the coronary arteries. The success of the technique is also due to the considerable technologic development of spiraI multidetector CT (MDCT) scanners, which has produced elevated spatial and temporal resolution, indispensable parameters for the study of the heart and the coronary tree. These structures are in fact characterized by significant and rapid motion, as well as vessels with millimetric diameters and tortuous course, and until a few years ago were considered beyond the capabilities of CT.