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Gianluca Pontone, MD, PhD, FESC, FSCCTDirector of MR UnitDeputy Director of Cardiovascul CT UnitClinical Cardiology UnitCentro Cardiologico Monzino, IRCCSUniversity of Milan, Italy

Imaging congestive heart failure: role ofcoronary computed tomography

angiography (CCTA)

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DISCLOSURE

SPEAKER BUREAU FOR GENERAL ELECTRIC

SPEAKER BUREAU FOR MEDTRONIC

SPEAKER BUREAU FOR BRACCO

RESEARCH GRANT FROM GENERAL ELECTRIC

RESEARCH GRANT FROM HEARTFLOW

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SUMMARY

Volume, function and remodellingVolume, function and remodelling

Rule out coronary arterydiseaseRule out coronary arterydisease

To evaluate LV myocardial damageTo evaluate LV myocardial damage

To evaluate cardiacveins anatomyTo evaluate cardiacveins anatomy

1. VOLUME, FUNCTION AND REMODELLING

Cury R, J Nucl Cardiol 2007

Global Left Ventricular Function: MDCT vs Echo/SPECT

Global Left Ventricular Function: MDCT vs MRI

Raman S, AHJ 2006

1. VOLUME, FUNCTION AND REMODELLING

Regional Left Ventricular Function: MDCT vs Echo

Lessick J AJC 2005

1. VOLUME, FUNCTION AND REMODELLING

Regional Left Ventricular Function: MDCT and SPECT vs MRI

MDCT vs MRI K:0.86SPECT vs MRI K: 0.51

1. VOLUME, FUNCTION AND REMODELLING

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Clinical implication on myocardial mass estimation

Armstrong A JACC CI 2012

1. VOLUME, FUNCTION AND REMODELLING

8Armstrong A JACC CI 2012

1. VOLUME, FUNCTION AND REMODELLING

Clinical implication on left ventricle volume estimation

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Systematic simulation of MR LV remodeling with respect tocontrol. The MR heart has the same LVES dimension(LVESD) as and a long-axis length similar to that of thecontrol. However, there is less curvature from the mid todistal LV segments represented by the dimmer red in the MRpatient vs control (bright yellow). These changes in the MRpatient contribute to a more spherical LV remodeling and alarger LVES volume.

Schiros CG Circulation 2012

1. VOLUME, FUNCTION AND REMODELLING

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Correlation between left ventricular (LV) end-systolicvolume (LVESV) and dimension (LVESD) in mitralregurgitation (MR) patients (A) and controlsubjects(B). The solid lines represent the fittedmodel for the LVESD vs LVESV relation with 95%confidence intervals (dash lines), which is cubic in MRpatients (n94) and quadratic in control subjects (n51).

The difference between the measuredLVESV from summated short-axis imagesand LVESV calculated from the Bulletformula in MR are plotted vs LVEScircumferential curvature at the distal LV.

Schiros CG Circulation 2012

1. VOLUME, FUNCTION AND REMODELLING

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1. VOLUME, FUNCTION AND REMODELLING

Left Ventricular Function: limitations

Temporal ResolutionSingle Source CT: 100 – 150 msecDual Source CT: 75 msecMRI, Echo < 50 msec

-blockade Because -blocker is generally used in MDCT, it can alter the functional parametrs and thus limit the utility of functional analysis

OtherMitral Plane and LVOTRadiation Exposure

1. VOLUME, FUNCTION AND REMODELLING

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SUMMARY

Volume, function and remodellingVolume, function and remodelling

Rule out coronary arterydiseaseRule out coronary arterydisease

To evaluate LV myocardial damageTo evaluate LV myocardial damage

To evaluate cardiacveins anatomyTo evaluate cardiacveins anatomy

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2. RULE OUT CAD

Andreini D, Pontone G, JACC 2007

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2. RULE OUT CAD

Andreini D, Pontone G, JACC 2007

*: P<0.05 Group 1(DCM)

Group 2(Control)

Number 61 139

Feasibility 97,2% 96,1%

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2. RULE OUT CAD

*: P<0.05 Group 1(DCM)

Group 2(Control)

Sensitivity 99% 86,1%*

Specificity 96,2% 96,4%

NPV 99,85 96,4%*

PPV 81,2% 86,1%

Andreini D, Pontone G, JACC 2007

… less motion artifacts in DCM population …

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2. RULE OUT CAD

LADD1

LCX

M1

LM

… not-evaluable segments were excluded from the analysis…

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2. RULE OUT CAD

Andreini D, Pontone G, Circulation CI 2009

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2. RULE OUT CAD

Andreini D, Pontone G, Circulation CI 2009

2. RULE OUT CAD

Dilated cardiomyopathy associated with severe CAD. Head-to-head comparison of invasive coronaryangiography (left panel) compared with MDCT multiplanar reconstruction (right panel). White arrows showsignificant stenosis on the proximal segments of left anterior descending artery (LAD), first marginal branch(M1), and right coronary artery (RCA).

Andreini D, Pontone G, Circulation CI 2009

2. RULE OUT CAD

Idiopathic form of dilated cardiomyopathy. Head-to-head comparison of MDCT multiplanar reconstruction(left panel) compared with invasive coronary angiography (right panel). LAD indicates left anteriordescending artery; LCX, left circumflex artery; RCA, right coronary artery.

Andreini D, Pontone G, Circulation CI 2009

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SUMMARY

Volume, function and remodellingVolume, function and remodelling

Rule out coronary arterydiseaseRule out coronary arterydisease

To evaluate LV myocardial damageTo evaluate LV myocardial damage

To evaluate cardiacveins anatomyTo evaluate cardiacveins anatomy

Attenuation

Thickness

3. TO EVALUATE LEFT VENTRICLE DAMAGE

Late Enhancement with MDCT

It is known that MRI can characterize MI with both early and latecontrast patterns. First-pass imaging performed immediately aftercontrast administration may demonstrate areas of hypoenhancement inthe endocardial core of the infarct corresponding to microvascularobstruction. Delayed images acquired more than 10 minutes aftercontrast administration may demonstrate regional hyperenhancement,corresponding to myocardial necrosis or scar. Because iodinatedcontrast agents used in CT have kinetics similar to gadolinium used inMRI, as discussed later, there is a rationale to believe that DHE-MDCTwould be able to identify areas of MI

3. TO EVALUATE LEFT VENTRICLE DAMAGE

Delayed Time: 5 – 10 min Tube Voltage: 80 Kv Tube Current: 420 mA Collimation: 64x0.625 mm Gantry Rotaion time: 350 msec ECG-gating: prospective ECG

Effective Radiation Dose: 1.19 – 1.61 mSv

Se Sp NPV PPV78% 100% 100% 97%

3. TO EVALUATE LEFT VENTRICLE DAMAGE

52 PTS with Acute MI PTCA+Stent CTLE and Tl-SPECT

0 and 6 Month

3. TO EVALUATE LEFT VENTRICLE DAMAGE

Transmural LE Subend. LE No LE

SATO A EHJ 2008

3. TO EVALUATE LEFT VENTRICLE DAMAGE

Significant increase of LVEDV only in transmural LE

Higher incidence of hospitalization only in transmural LE

3. TO EVALUATE LEFT VENTRICLE DAMAGE

Late Enhancement 0 = no LELate Enhancement 1: 1% - 25%Late Enhancement 2: 26% - 50%Late Enhancement 3: 51% - 75%Late Enhancement 4: : >75%

3. TO EVALUATE LEFT VENTRICLE DAMAGE

DELINEATION OF THE ETIOLOGY OF LV DYSFUNCTION

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DELINEATION OF THE ETIOLOGY OF LV DYSFUNCTION

Le Polain De Waroix et al EHJ 2008

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Se Sp Accuracy92% 97% 94%

DELINEATION OF THE ETIOLOGY OF LV DYSFUNCTION

Le Polain De Waroix et al EHJ 2008

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SUMMARY

Volume, function and remodellingVolume, function and remodelling

Rule out coronary arterydiseaseRule out coronary arterydisease

To evaluate LV myocardial damageTo evaluate LV myocardial damage

To evaluate cardiacveins anatomyTo evaluate cardiacveins anatomy

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4. CARDIAC VEINS ANATOMY

35Pontone G IJC 2009

4. CARDIAC VEINS ANATOMY

36Pontone G IJC 2009

4. CARDIAC VEINS ANATOMY

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4. CARDIAC VEINS ANATOMY

DCM: lower percentage of cardiac veins

DCM without specific protocol: more artifacts

No differences between DCM and control regard to anatomical details ofveins

PVLV and LMV are less in all groups

Ischemic DCM group shows the less suitable anatomy for CRT

CS

MCV

PV

GCV

GCV

PV

LMV

GCV

LMVAIV

LEGENDSCS: coronary sinus; MCV: middle cardiac vein; PV: posterior vein;GCV: great cardiac vein; LMV: left marginal vein; AIV: anteriorinterventricular vein.

Normal Cardiac Veins anatomy

4. CARDIAC VEINS ANATOMY

Great Cardiac Veins from SVC

4. CARDIAC VEINS ANATOMY

Fistula between greta cardiac vein and left atrial appendage

4. CARDIAC VEINS ANATOMY

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4. CARDIAC VEINS ANATOMY

Giraldi F, Pontone G et al JACC 2011

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4. CARDIAC VEINS ANATOMY

Giraldi F, Pontone G et al JACC 2011

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4. CARDIAC VEINS ANATOMY

Giraldi F, Pontone G et al JACC 2011

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TAKE HOME MESSAGE

Giraldi F, Pontone G et al JACC 2011