CT / MR: Clinical Results and Usefulness for the Interventional Cardiologist

Jeffrey C. Hellinger, MDAssociate Professor of Radiology and Pediatrics

Associate Director of Advanced Cardiovascular ImagingStony Brook University School of Medicine

Stony Brook, NY USA

MDCT & MRI: Where We AreApril 29, 2010

ANGIOPLASTY SUMMIT TCTAP2010TRANSCATHETER CARDIOVASCULAR THERAPIES ASIA PACIFICApril 28 – 30 Seoul, Korea

CVCT / CVMR: Clinical Innovation

§ Acquisition§ Transmission§ Interpretation / Post – Processing§ Storage and Retrieval

§ Diagnosis § Treatment planning§ Intraprocedural

§ Guidance§ Monitoring

Advanced visualization techniques

Display Principal use

Advantages Disadvantages

MIP 2D •Structural overview

•“Slice” through dataset in axial, coronal, sagittal, & oblique proj•Real-time multiplanar interrogation•Depict small caliber structures•Depict lower enhanced structures•Communicate findings

•Anatomical overlap•Visualization degraded by high density (CT)/Intensity(MRI) structures•Loss of structural detail with ↑ slab thickness

VR 3D •Structural overview

•“Slice” through dataset in axial, coronal, sagittal, & oblique proj•Real-time multiplanar interrogation•Depict structural relationships•Accurate spatial perception•Communicate findings

•Opacity-transfer function dependent•Anatomical overlap•Loss of structural detail with ↑ slab thickness

Advanced visualization techniques

Display Principal use Advantages Disadvantages

MPR 2D • Structural details• Quantitativeanalysis

•“Slice” through dataset in coronal, sagittal, & oblique projections•Real-time multiplanar interrogation•Simplify image interpretation•Single anatomical display

Limited spatial perception

CPR 2D •Structural details•Centerline display•Simplify MPR

Single anatomical displayLongitudinal cross-sectionalanatomical display

Operator dependent

Ray sum

2D •Structural overview •“Slice” through dataset in axial, coronal, sagittal, & oblique projections•Real-time multiplanar interrogation•Radiograph like display

Loss of structural detail with ↑ slabthickness

CCT: Early Performance

N = 5485% sent home from ER

N = 39Sens = 89%Spec = 95%PPV = 94%NPV = 90%

2008 2009 2010

mSv=3.2 mSv=1.3 mSv=0.5

mSv=0.33

mSv=0.22

0

5

10

15

20

25

30

0 2.5 5 7.5 10 12.5 15 17.5

Freq

uenc

y

Arterial mSv WITH Weighting Factor

Histogram

Normal Fit(Mean=4.8900, SD=3.3217)

mSv: with age weighting Factor (4.9) Pediatric CCT at 80KV

Arterial mSv WO Weighting Factor14

12

10

8

6

4

2

0

Kvp80 100 120

60% reduction

Standard Spiral sedated

Flash Spiral not sedated

Standard Spiral not sedated

Flash Spiral ScanningPediatric motion simulation

§ Improving plaque characterization§ Increasing spatial resolution § Simplifying workflow: improving efficiency§ Improving patient comfort

CVMR: Current Directions

MRA NATIVE TrueFISP

Inflowing blood

Background

Inverted blood

• TI

selective inversion

imaging

Inversion ImagingInflowTI

NATIVE TrueFISP

Time Resolved MR Angiography

A B A B A B A Bl l l l l l

time

TA TB TA = NA x TR

TB = s x NB x TR

A B

with 0 = s = 100[ %]< <

“temporalresolution”

TimCT Angiography

Conventional

easier workflow

TimCT

*Results may vary. Data on file.

Time Resolved MR Angiography

TimCT AngiographyContinuous Table move

TimCT Angiography

LMU, Munich, Germany

Multi-step Angiography TimCT Angiography

§ C – Arm CT § Interventional – MRI unit

The Interventional Cardiology Suit

§ Pre-procedural imaging§ Intra-procedural guidance§ Real – time monitoring

Workflow 3D guidance in EP

syngo DynaCT Cardiac

syngo inSpace EP

syngo iPilot

syngo iGuideToolbox

3D acquisition Segmentation

3D Overlayon live fluoro Guidance

+

+

+ +

+

+

+

+

syngo DynaCT Cardiac

syngo inSpace EP

3D acquisition Segmentation

3D Overlayon live fluoro Guidance

syngo DynaCT Cardiac

syngo inSpace EP

3D acquisition Segmentation

§ Noninvasive CVCT and CVMR are useful adjuncts to interventional cardiology practice § CCT has rapidly revolutionized clinical algorithms§ Latest 3rd Generation MDCT scanners will further advance clinical care. Lower radiation dose with high image quality is the goal. New DATA is necessary§ New advances in MRI: plaque characterization, MRA sequences will challenge MDCT§ Interventional Cardiology suit is actively changing: CT and MR multiplanar soft tissue and angiographic visualization capabilities

Conclusions

Thank you for your attention

MDCT & MRI: Where We AreApril 29, 2010

ANGIOPLASTY SUMMIT TCTAP2010TRANSCATHETER CARDIOVASCULAR THERAPIES ASIA PACIFICApril 28 – 30 Seoul, Korea