Prospective versus retrospective ECG-gated 64-detector coronary CT angiography for evaluation of coronary artery bypass graft patency: comparison of image quality, radiation dose and diagnostic accuracy

Role of MDCT in Assessment of Long-term Graft Patency in Female Patients

Objectives:

The aim of the study was to analyze the utility of CT-coronary angiogram (CT-CAG) in assessment of long-term graft patency compared to conventional invasive coronary angiography (ICA) and highlight any gender-specific issues in female post-coronary artery bypass surgery (CABG) patients.

Materials and Methods:

The medical records and images of 30 patients including four female patients who had CABG in the past and underwent both conventional and CT-CAGs were analyzed retrospectively.

Results:

We studied 30 patients who had CABG in whom both CT-CAG and conventional coronary angiograms were performed. CT-CAG was able to evaluate the grafts better than ICA and was useful even in those which could not be assessed due to technical failure by ICA. There were only four female patients in this series. In first patient, the arterial graft (left internal mammary artery [LIMA]) was patent but distal run off was absent in LAD in CT-CAG images and was reported as poor in conventional coronary angiogram. The second patient had CABG 10 years back. The arterial graft (LIMA) to LAD was patent and there was total block in SVG graft to RCA at proximal anastomotic site. The third patient with hypertension and diabetes also had CABG 10 years back. Both LIMA to LAD and SVG to PDA were patent in her. In last case who had CABG 7 years, two of the three SVG grafts were blocked which were well-demonstrated on CT CAG, including one SVG missed on conventional CAG.

Conclusion:

CT-CAG is a non-invasive and less cumbersome alternative to conventional CAG for the assessment of grafts long after CABG even in women. The data generated by CT-CAG in post-CABG are as good as the invasive CAG and it has distinct advantage of greater acceptability.

Diagnostic accuracy of 256-row multidetector CT coronary angiography with prospective ECG-gating combined with fourth-generation iterative reconstruction algorithm in the assessment of coronary artery bypass: evaluation of dose reduction and image quality

BACKGROUND

Effective radiation dose in coronary CT angiography (CTCA) for coronary artery bypass graft (CABG) evaluation is remarkably high because of long scan lengths. Prospective electrocardiographic gating with iterative reconstruction can reduce effective radiation dose.

OBJECTIVES

To evaluate the diagnostic performance of low-kV CT angiography protocol with prospective ecg-gating technique and iterative reconstruction (IR) algorithm in follow-up of CABG patients compared with standard retrospective protocol.

METHODS

Seventy-four non-obese patients with known coronary disease treated with artery bypass grafting were prospectively enrolled. All the patients underwent 256 MDCT (Brilliance iCT, Philips) CTCA using low-dose protocol (100 kV; 800 mAs; rotation time: 0.275 s) combined with prospective ECG-triggering acquisition and fourth-generation IR technique (iDose⁴; Philips); all the lengths of the bypass graft were included in the evaluation. A control group of 42 similar patients was evaluated with a standard retrospective ECG-gated CTCA (100 kV; 800 mAs).On both CT examinations, ROIs were placed to calculate standard deviation of pixel values and intra-vessel density. Diagnostic quality was also evaluated using a 4-point quality scale.

RESULTS

Despite the statistically significant reduction of radiation dose evaluated with DLP (study group mean DLP: 274 mGy cm; control group mean DLP: 1224 mGy cm; P value < 0.001). No statistical differences were found between PGA group and RGH group regarding intra-vessel density absolute values and SNR. Qualitative analysis, evaluated by two radiologists in "double blind", did not reveal any significant difference in diagnostic quality of the two groups.

CONCLUSIONS

The development of high-speed MDCT scans combined with modern IR allows an accurate evaluation of CABG with prospective ECG-gating protocols in a single breath hold, obtaining a significant reduction in radiation dose.

CT angio for the evaluation of graft patency

Invasive coronary angiography (ICA) is the traditional method for the follow-up of graft patency in coronary artery bypass graft (CABG) patients. Nevertheless, the advent of multidetector computed tomography (MDCT) opened new perspectives for using a noninvasive, equally reliable method to study CABG patients. This review article will analyze the current feasibility of modern multi-slice MDCT, as well as its future perspectives.

A systematic review and meta-analysis of multidetector computed tomography in the assessment of coronary artery bypass grafts

PURPOSE

The present meta-analysis aimed to compare the diagnostic accuracy of more recent computed tomography coronary angiography (CTCA) with invasive coronary angiography (ICA) in the assessment of graft patency after coronary artery bypass graft surgery (CABG).

MATERIAL AND METHODS

A systematic review was performed using nine electronic databases from their dates of inception to July 2015. Predefined inclusion criteria included studies reporting on comparative outcomes using ≥64 slice multidetector computed tomography (MDCT) and ICA. The primary endpoints included graft occlusion and significant graft stenosis ≥50%. Secondary analyses included the comparison of arterial versus venous graft conduits, and the use of different MDCT techniques.

RESULTS

Thirty-one studies were identified according to selection criteria, involving 1975 patients with 5364 assessed grafts. Combined assessment of stenosis and occlusion for all grafts demonstrated a sensitivity of 96.1% [95% confidence interval (CI) 94.3-97.4%] and specificity of 96.3% (95% CI 95.1-97.3%). CTCA assessment of venous grafts demonstrated higher sensitivity compared to arterial grafts, when testing for both occlusion and stenosis (97.6% vs 89.2%, p=0.004).

CONCLUSION

Results of this study demonstrated that CTCA had a relatively high pooled sensitivity, specificity and negative predictive value compared to ICA. However, patient baseline characteristics varied between studies, and the results should be interpreted with caution. Nonetheless, our results indicate that CTCA should be recognized as an accurate and non-invasive investigation for graft patency in symptomatic patients after CABG.

Organ and effective dose evaluation in coronary angiography by using a 320 MDCT based on in-phantom dose measurements with TLDs

The purpose of this study is to estimate the organ and effective dose (E) from computed tomography coronary angiography (CTCA) on a 320-MDCT scanner. Radiation dose was estimated for the prospectively ECG-gated CTCA in a male phantom. A total of 451 chips of thermoluminescent dosimeter were implanted in the phantom for measuring the organ doses. The effective doses were calculated using measured organ doses and the tissue-weighting factors. The dose length product (DLP) values were recorded and used to develop the conversion coefficient k = 0.017 mSv•(mGy•cm)(-1) (E/DLP). In a 3-beat acquisition, the organ doses ranged from 0.24 to 71.55 mGy, and the doses in breast, bone surface, oesophagus, and lung were higher than 20 mGy. The effective doses in 2-beat and 3-beat acquisition were estimated to be 14.3 and 24.3 mSv. More beats of acquisition led to higher radiation dose. The reported k values for chest CT scan can be used to roughly estimate the E value from CTCA for 320 MDCT.

256-slice CT angiographic evaluation of coronary artery bypass grafts: effect of heart rate, heart rate variability and Z-axis location on image quality

Purpose

The objective of this study is to assess the effect of heart rate, heart rate variability and z-axis location on coronary artery bypass graft (CABG) image quality using a 256-slice computed tomography (CT) scanner.

Methods

A total of 78 patients with 254 CABG (762 graft segments) were recruited to undergo CABG assessment with 256-slice CT and prospective ECG-gating. Two observers rated graft segments for image quality on a 5-point scale. Quantitative measurements were also made. Logistic and cumulative link mixed models were used to assess the predictors of graft image quality.

Results

Graft image quality was judged as diagnostic (scores 5 (excellent), 4 (good) and 3 (moderate)) in 96.6% of the 762 segments. Interobserver agreement was excellent (kappa ≥0.90). Graft image quality was not affected by heart rate level. However, high heart rate variability was associated with an important and significant image quality deterioration (odds ratio 4.31; p  =  0.036). Distal graft segments had significantly lower image quality scores than proximal segments (p ≤ 0.02). Significantly higher noise was noted at the origin of the mammary grafts (p  =  0.001), owing to streak artifacts from the shoulders.

Conclusion

CABG imaging with 270-msec rotation 256-slice CT and prospective ECG-gating showed an adequate image quality in 96.6% of graft segments, and an excellent interobserver agreement. Graft image quality was not influenced by heart rate level. Image quality scores were however significantly decreased in patients with high heart rate variability, as well as in distal graft segments, which are closer to the heart.

Computed tomography angiography of coronary artery bypass grafts: robustness in emergency and clinical routine settings

BACKGROUND

There is a high probability for presence of irregular heart rates and artifacts in patients with previous coronary artery bypass graft (CABG) surgery. Previously reported diagnostic performance of ECG-gated 64-slice dual-source computer tomography angiography (CTA) in this patient group is based on pre-selection for normal heart rate and routine clinical setting.

PURPOSE

To investigate image quality and diagnostic performance of CTA in patients with previous CABG surgery in various clinical settings.

MATERIAL AND METHODS

Fifty-six non-selected, consecutive patients (110 grafts, 44 arterial, 66 venous) with previous CABG surgery were prospectively examined using a dual-source 64-slice CT (Siemens Definition, Forchheim, Germany) without utilization of CT-related pharmaceutical heart rate control. Patients were stratified according to the clinical setting: planned redo-cardiac surgery; emergency CTA within 30 days after CABG surgery; routine follow-up after CABG surgery. A reference standard was available for 30 patients (53.6%; 67/110 grafts). Image quality, artifacts, and graft patency were independently assessed by two observers.

RESULTS

All CTAs were diagnostic despite the presence of irregular heart rhythm (25% of cases) and artifacts (72.7% of grafts). CTA was accurate in all patient groups in assessing graft patency (97.9% sensitivity; 100% specificity; 98.5% accuracy) but artifacts decreased diagnostic performance for stenosis detection (60% sensitivity; 88.6% specificity; 84.1% accuracy). Arterial grafts exhibited more surgical clip artifacts compared to venous grafts, which predominantly showed motion artifacts. Overall diagnostic quality was rated excellent in 70.9%/56.4%, good in 23.4%/39.1%, and sufficient in 5.5%/4.5% by each observer, respectively. CTA detected acute findings in 10 cases (graft bleeding, graft occlusion, pericardial hematoma, sternal instability with retrosternal abscess formation, pericardial effusion, left ventricle thrombus) in the emergency group; seven cases required surgical revision.

CONCLUSION

Dual-source CTA is a robust and accurate method for assessment of graft patency and detection of relevant extra-cardiac pathologies in a non-selected patient population after CABG surgery in routine as well as emergency clinical settings. Artifacts caused by irregular heart rhythm or surgical clips do not impair graft patency evaluation but limit stenosis assessment.

Impact of a new motion-correction algorithm on image quality of low-dose coronary CT angiography in patients with insufficient heart rate control

RATIONALE AND OBJECTIVES

Prospective electrocardiogram (ECG) triggering allows coronary computed tomography angiography (CCTA) scanning with low radiation dose but requires heart rates below 63 beats/min. We assessed the impact of a novel vendor-specific motion-correction algorithm on image quality and interpretability of low-dose CCTA acquired despite insufficient heart rate control.

MATERIALS AND METHODS

In 40 patients undergoing CCTA for the assessment of known or suspected coronary artery disease who did not reach the target heart rate below 63 beats/min despite β-blockade before prospective low-dose scanning, the temporal acquisition window was increased (80 ms additional padding). The new algorithm detects and integrates vessel path and velocity from adjacent cardiac phases for motion correction. Two blinded observers assessed image quality on a 4-point Likert scale (1, nonevaluative; 2, reduced but evaluative; 3, good; and 4, excellent) and the fraction of interpretable segments (score 2 or more) using motion correction versus standard reconstruction.

RESULTS

Image reconstruction with motion correction resulted in an increased median coronary artery image quality score (excellent interobserver agreement, κ = 0.85) compared to standard reconstruction (3.4 vs. 3.0, P < .001). Consequently, motion-corrected reconstruction significantly improved the overall interpretability of coronary arteries (from 78% to 88%, P < .001). Estimated mean effective radiation dose was 2.3 ± 0.8 mSv.

CONCLUSIONS

A novel, vendor-specific, motion-corrected, reconstruction algorithm improves image quality and interpretability of prospectively ECG-triggered low-dose CCTA despite insufficient heart rate control.

CT coronary angiography: impact of adapted statistical iterative reconstruction (ASIR) on coronary stenosis and plaque composition analysis

To assess the impact of adaptive statistical iterative reconstruction (ASIR) on coronary plaque volume and composition analysis as well as on stenosis quantification in high definition coronary computed tomography angiography (CCTA). We included 50 plaques in 29 consecutive patients who were referred for the assessment of known or suspected coronary artery disease (CAD) with contrast-enhanced CCTA on a 64-slice high definition CT scanner (Discovery HD 750, GE Healthcare). CCTA scans were reconstructed with standard filtered back projection (FBP) with no ASIR (0 %) or with increasing contributions of ASIR, i.e. 20, 40, 60, 80 and 100 % (no FBP). Plaque analysis (volume, components and stenosis degree) was performed using a previously validated automated software. Mean values for minimal diameter and minimal area as well as degree of stenosis did not change significantly using different ASIR reconstructions. There was virtually no impact of reconstruction algorithms on mean plaque volume or plaque composition (e.g. soft, intermediate and calcified component). However, with increasing ASIR contribution, the percentage of plaque volume component between 401 and 500 HU decreased significantly (p < 0.05). Modern image reconstruction algorithms such as ASIR, which has been developed for noise reduction in latest high resolution CCTA scans, can be used reliably without interfering with the plaque analysis and stenosis severity assessment.