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van der Werf NR, Rodesch PA, Si-Mohamed S, van Hamersvelt RW, Greuter MJW, Leiner T, Boussel L, Willemink MJ, Douek P. Improved coronary calcium detection and quantification with low-dose full field-of-view photon-counting CT: a phantom study. Eur Radiol 2022; 32:3447-3457. [PMID: 34997284 DOI: 10.1007/s00330-021-08421-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 08/31/2021] [Accepted: 10/17/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The aim of the current study was to systematically assess coronary artery calcium (CAC) detection and quantification for spectral photon-counting CT (SPCCT) in comparison to conventional CT and, in addition, to evaluate the possibility of radiation dose reduction. METHODS Routine clinical CAC CT protocols were used for data acquisition and reconstruction of two CAC containing cylindrical inserts which were positioned within an anthropomorphic thorax phantom. In addition, data was acquired at 50% lower radiation dose by reducing tube current, and slice thickness was decreased. Calcifications were considered detectable when three adjacent voxels exceeded the CAC scoring threshold of 130 Hounsfield units (HU). Quantification of CAC (as volume and mass score) was assessed by comparison with known physical quantities. RESULTS In comparison with CT, SPCCT detected 33% and 7% more calcifications for the small and large phantoms, respectively. At reduced radiation dose and reduced slice thickness, small phantom CAC detection increased by 108% and 150% for CT and SPCCT, respectively. For the large phantom size, noise levels interfered with CAC detection. Although comparable between CT and SPCCT, routine protocols CAC quantification showed large deviations (up to 134%) from physical CAC volume. At reduced radiation dose and slice thickness, physical volume overestimations decreased to 96% and 72% for CT and SPCCT, respectively. In comparison with volume scores, mass score deviations from physical quantities were smaller. CONCLUSION CAC detection on SPCCT is superior to CT, and was even preserved at a reduced radiation dose. Furthermore, SPCCT allows for improved physical volume estimation. KEY POINTS • In comparison with conventional CT, increased coronary artery calcium detection (up to 156%) for spectral photon-counting CT was found, even at 50% radiation dose reduction. • Spectral photon-counting CT can more accurately measure physical volumes than conventional CT, especially at reduced slice thickness and for high-density coronary artery calcium. • For both conventional and spectral photon-counting CT, reduced slice thickness reconstructions result in more accurate physical mass approximation.
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Affiliation(s)
- N R van der Werf
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands. .,Department of Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - P A Rodesch
- Louis Pradel Cardiology Hospital, Hospices Civils de Lyon, Lyon, France.,Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1206, Lyon, France
| | - S Si-Mohamed
- Louis Pradel Cardiology Hospital, Hospices Civils de Lyon, Lyon, France.,Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1206, Lyon, France
| | - R W van Hamersvelt
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M J W Greuter
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - T Leiner
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - L Boussel
- Louis Pradel Cardiology Hospital, Hospices Civils de Lyon, Lyon, France.,Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1206, Lyon, France
| | - M J Willemink
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - P Douek
- Louis Pradel Cardiology Hospital, Hospices Civils de Lyon, Lyon, France.,Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1206, Lyon, France
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Kamani CH, Huang W, Lutz J, Giannopoulos AA, Patriki D, von Felten E, Schwyzer M, Gebhard C, Benz DC, Fuchs TA, Gräni C, Pazhenkottil AP, Kaufmann PA, Buechel RR. Impact of Adaptive Statistical Iterative Reconstruction-V on Coronary Artery Calcium Scores Obtained From Low-Tube-Voltage Computed Tomography - A Patient Study. Acad Radiol 2022; 29 Suppl 4:S11-S16. [PMID: 33187851 DOI: 10.1016/j.acra.2020.10.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 10/16/2020] [Accepted: 10/24/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the impact of adaptive statistical iterative reconstruction-V (ASIR-V) on the accuracy of ultra-low-dose coronary artery calcium (CAC) scoring. MATERIALS AND METHOD One-hundred-and-three patients who underwent computed tomography (CT) for CAC scoring were prospectively included. All underwent standard scanning with 120-kilovolt-peak (kVp) and with 80- and 70-kVp tube voltage. ASiR-V was applied to the 80- and 70-kVp scans at different levels. The 120-kVp scans reconstructed with filtered back projection served as the standard of reference. Recently published novel kVp-adapted thresholds were used for calculation of CAC scores from 80- and 70-kVp scans and the resulting CAC scores were compared against the standard of reference. Patients were stratified into six CAC score risk categories: 0, 1-10, 11-100, 101-400, 401-1000, and >1000. RESULTS Increasing levels of ASIR-V led to an increasing underestimation of CAC scores with bias ranging from -128 to -118 and from -205 to -198 for the 80- and 70-kVp scans, respectively, when compared with the standard of reference. Reconstruction with 20% and 40% ASIR-V for the 80- and 70-kVp scans, respectively, yielded noise levels comparable to the standard of reference. Nevertheless, a change in risk-class was observed in 29 (28.6%) and 46 (44.7%) patients, exclusively to a lower risk-class, when CAC scores were derived from these reconstructions. CONCLUSION ASIR-V leads to noise reduction in CT scans acquired with low tube-voltages. However, ASIR-V introduces substantial inaccuracies and marked underestimation of ultra-low-dose CAC scoring as compared with standard-dose CAC scoring despite normalization of noise.
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Affiliation(s)
- Christel H Kamani
- University Hospital Zürich, Rämistrasse 100, 8091 Zürich, SWITZERLAND
| | - Wenjie Huang
- University Hospital Zürich, Rämistrasse 100, 8091 Zürich, SWITZERLAND
| | - Joel Lutz
- University Hospital Zürich, Rämistrasse 100, 8091 Zürich, SWITZERLAND
| | | | - Dimitri Patriki
- University Hospital Zürich, Rämistrasse 100, 8091 Zürich, SWITZERLAND
| | - Elia von Felten
- University Hospital Zürich, Rämistrasse 100, 8091 Zürich, SWITZERLAND
| | - Moritz Schwyzer
- University Hospital Zürich, Rämistrasse 100, 8091 Zürich, SWITZERLAND
| | - Catherine Gebhard
- University Hospital Zürich, Rämistrasse 100, 8091 Zürich, SWITZERLAND
| | - Dominik C Benz
- University Hospital Zürich, Rämistrasse 100, 8091 Zürich, SWITZERLAND
| | - Tobias A Fuchs
- University Hospital Zürich, Rämistrasse 100, 8091 Zürich, SWITZERLAND
| | - Christoph Gräni
- University Hospital Zürich, Rämistrasse 100, 8091 Zürich, SWITZERLAND
| | | | | | - Ronny R Buechel
- University Hospital Zürich, Rämistrasse 100, 8091 Zürich, SWITZERLAND.
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van Praagh GD, Wang J, van der Werf NR, Greuter MJW, Mastrodicasa D, Nieman K, van Hamersvelt RW, Oostveen LJ, de Lange F, Slart RHJA, Leiner T, Fleischmann D, Willemink MJ. Coronary Artery Calcium Scoring: Toward a New Standard. Invest Radiol 2022; 57:13-22. [PMID: 34261083 PMCID: PMC10072789 DOI: 10.1097/rli.0000000000000808] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Although the Agatston score is a commonly used quantification method, rescan reproducibility is suboptimal, and different CT scanners result in different scores. In 2007, McCollough et al (Radiology 2007;243:527-538) proposed a standard for coronary artery calcium quantification. Advancements in CT technology over the last decade, however, allow for improved acquisition and reconstruction methods. This study aims to investigate the feasibility of a reproducible reduced dose alternative of the standardized approach for coronary artery calcium quantification on state-of-the-art CT systems from 4 major vendors. MATERIALS AND METHODS An anthropomorphic phantom containing 9 calcifications and 2 extension rings were used. Images were acquired with 4 state-of-the-art CT systems using routine protocols and a variety of tube voltages (80-120 kV), tube currents (100% to 25% dose levels), slice thicknesses (3/2.5 and 1/1.25 mm), and reconstruction techniques (filtered back projection and iterative reconstruction). Every protocol was scanned 5 times after repositioning the phantom to assess reproducibility. Calcifications were quantified as Agatston scores. RESULTS Reducing tube voltage to 100 kV, dose to 75%, and slice thickness to 1 or 1.25 mm combined with higher iterative reconstruction levels resulted in an on average 36% lower intrascanner variability (interquartile range) compared with the standard 120 kV protocol. Interscanner variability per phantom size decreased by 34% on average. With the standard protocol, on average, 6.2 ± 0.4 calcifications were detected, whereas 7.0 ± 0.4 were detected with the proposed protocol. Pairwise comparisons of Agatston scores between scanners within the same phantom size demonstrated 3 significantly different comparisons at the standard protocol (P < 0.05), whereas no significantly different comparisons arose at the proposed protocol (P > 0.05). CONCLUSIONS On state-of-the-art CT systems of 4 different vendors, a 25% reduced dose, thin-slice calcium scoring protocol led to improved intrascanner and interscanner reproducibility and increased detectability of small and low-density calcifications in this phantom. The protocol should be extensively validated before clinical use, but it could potentially improve clinical interscanner/interinstitutional reproducibility and enable more consistent risk assessment and treatment strategies.
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Affiliation(s)
| | - Jia Wang
- Department of Environmental Health and Safety, Stanford University, Stanford CA
| | | | | | | | | | | | - Luuk J Oostveen
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen
| | - Frank de Lange
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen
| | | | - Tim Leiner
- Department of Radiology, University Medical Center Utrecht, Utrecht
| | | | - Martin J Willemink
- From the Department of Radiology, Stanford University School of Medicine, Stanford, CA
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Histogram-derived modified thresholds for coronary artery calcium scoring with lower tube voltage. Sci Rep 2021; 11:17450. [PMID: 34465816 PMCID: PMC8408203 DOI: 10.1038/s41598-021-96695-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/13/2021] [Indexed: 12/15/2022] Open
Abstract
We aimed to determine the proper modified thresholds for detecting and weighting CAC scores at 100 kV through histogram matching in comparison with 120 kV as a standard reference. From the training set (680 participants), modified thresholds at 100 kV were obtained through histogram matching of calcium pixels to 120 kV. From the validation set (213 participants), a standard CAC score at 120 kV, and modified CAC score at 100 kV using modified thresholds were compare through the paired t test and the Bland–Altman plot. Agreement for risk categories (no, minimal, mild, moderate, and severe) was evaluated using kappa statistics. Radiation doses were also compared. For the validation set, there was no significant difference between standard (median, 18.7; IQR, 0.0–207.0) and modified (median, 17.3; IQR, 0.0–220.9) CAC scores (P = 0.689). A small bias was achieved (0.74) with 95% limits of agreement from − 52.35 to 53.83. Agreements for risk categories were excellent (κ = 0.994). The mean dose-length-product of 100-kV scanning (30.1 ± 0.8 mGy * cm) was significantly decreased compared to 120-kV scanning (42.9 ± 0.6 mGy * cm) (P < 0.001). Histogram-derived modified thresholds at 100 kV can enable accurate CAC scoring while reducing radiation exposure.
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Pan YK, Sun MH, Wang JJ, Chen XB, Kan XJ, Ge YH, Guo ZP. Effect of different reconstruction algorithms on coronary artery calcium scores using the reduced radiation dose protocol: a clinical and phantom study. Quant Imaging Med Surg 2021; 11:1504-1517. [PMID: 33816187 DOI: 10.21037/qims-20-437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background This study aimed to evaluate the effects of different iterative reconstruction (IR) algorithms on coronary artery calcium (CAC) score quantification using the reduced radiation dose (RRD) protocol in an anthropomorphic phantom and in patients. Methods A thorax phantom, containing 9 calcification inserts with varying hydroxyapatite (HA) densities, was scanned with the reference protocol [120 kv, 80 mAs, filtered back projection (FBP)] and RRD protocol (120 kV, 20-80 mAs, 5 mAs interval) using a 256-slice computed tomography (CT) scanner. Raw data were reconstructed with different reconstruction algorithms [iDose4 levels 1-7 and iterative model reconstruction (IMR) levels 1-3]. Signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and Agatston score (AS) were calculated for each image series. The correction factor was derived from linear regression analysis between the reference image series and other image series with different parameters. Additionally, 40 patients were scanned with the RRD protocol (50 mAs) and reconstructed with FBP, iDose4 level 4, and IMR level 2. AS was calculated for the 3-group image series, and was corrected by applying a correction factor for the IMR group. The agreement of risk stratification with different reconstruction algorithms was also analyzed. Results For the phantom study, the iDose4 and IMR groups had significantly higher SNR and CNR than the FBP group (all P<0.05). There were no significant differences in the total AS after comparing image series reconstructed with iDose4 (level 1-7) and FBP (all P>0.05), while AS from the IMR (level 1-3) image series were lower than the FBP group (all P<0.05). The tube current of 50 mAs was determined for the clinical study, and the correction factor was 1.14. For the clinical study, the median AS from the iDose4 and IMR groups were both significantly lower compared to the FBP image series [(112.89 (63.01, 314.09), 113.22 (64.78, 364.95) vs. 118.59 (65.05, 374.48), both P<0.05]. After applying the correction factor, the adjusted AS from the IMR group was not significantly different from that of the FBP group [126.48 (69.62, 355.85) vs. 118.59 (65.05, 374.48), P=0.145]. Moreover, the agreement in risk stratification between FBP and IMR improved from 0.81 to 0.85. Conclusions The RRD CAC scoring scan using the IMR reconstruction algorithm is clinically feasible, and a correction factor can help reduce the AS underestimation effect.
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Affiliation(s)
- Yu-Kun Pan
- Department of Radiology, Central China Fuwai Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Ming-Hua Sun
- Department of Radiology, Henan Provincial People's Hospital, Department of Radiology of Central China Fuwai Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China
| | - Jia-Jia Wang
- Department of Radiology, Central China Fuwai Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | | | - Xiao-Jing Kan
- Department of Radiology, Henan Provincial People's Hospital, Department of Radiology of Central China Fuwai Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China
| | - Ying-Hui Ge
- Department of Radiology, Henan Provincial People's Hospital, Department of Radiology of Central China Fuwai Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China
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Vonder M, van der Werf NR, Leiner T, Greuter MJ, Fleischmann D, Vliegenthart R, Oudkerk M, Willemink MJ. The impact of dose reduction on the quantification of coronary artery calcifications and risk categorization: A systematic review. J Cardiovasc Comput Tomogr 2018; 12:352-363. [DOI: 10.1016/j.jcct.2018.06.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 05/18/2018] [Accepted: 06/11/2018] [Indexed: 11/29/2022]
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Große Hokamp N, Höink AJ, Doerner J, Jordan DW, Pahn G, Persigehl T, Maintz D, Haneder S. Assessment of arterially hyper-enhancing liver lesions using virtual monoenergetic images from spectral detector CT: phantom and patient experience. Abdom Radiol (NY) 2018; 43:2066-2074. [PMID: 29185013 DOI: 10.1007/s00261-017-1411-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To investigate a benefit from virtual monoenergetic reconstructions (VMIs) for assessment of arterially hyper-enhancing liver lesions in phantom and patients and to compare hybrid-iterative and spectral image reconstructions of conventional images (CI-IR and CI-SR). METHODS All imaging was performed on a SDCT (Philips Healthcare, Best, The Netherlands). Images of a non-anthropomorphic phantom with a lesion-mimicking insert (containing iodine in water solution) and arterial-phase images from contrast-enhanced patient examinations were evaluated. VMIs (40-200 keV, 10 keV increment), CI-IR, and CI-SR were reconstructed using different strengths of image denoising. ROIs were placed in lesions, liver/matrix, muscle; signal-to-noise, contrast-to-noise, and lesion-to-liver ratios (SNR, CNR, and LLR) were calculated. Qualitatively, 40, 70, and 110 keV and CI images were assessed by two radiologists on five-point Likert scales regarding overall image quality, lesion assessment, and noise. RESULTS In phantoms, SNR was increased threefold by VMI40keV compared with CI-IR/SR (5.8 ± 1.1 vs. 18.8 ± 2.2, p ≤ 0.001), while no difference was found between CI-IR and CI-SR (p = 1). Denoising was capable of noise reduction by 40%. In total, 20 patients exhibiting 51 liver lesions were assessed. Attenuation was the highest in VMI40keV, while image noise was comparable to CI-IR resulting in a threefold increase of CNR/LLR (CI-IR 1.3 ± 0.8/4.4 ± 2.0, VMI40keV: 3.8 ± 2.7/14.2 ± 7.5, p ≤ 0.001). Subjective lesion delineation was the best in VMI40keV image (p ≤ 0.01), which also provided the lowest perceptible noise and the best overall image quality. CONCLUSIONS VMIs improve assessment of arterially hyper-enhancing liver lesions since they increase lesion contrast while maintaining low image noise throughout the entire keV spectrum. These data suggest that to consider VMI screening after arterially hyper-enhancing liver lesions.
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Affiliation(s)
- N Große Hokamp
- Department of Diagnostic and Interventional Radiology, University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
- Department of Radiology, University Hospitals Cleveland, Cleveland, OH, USA.
- Department of Radiology, School of Medicine, Case Western Reserve University, Cleveland, OH, USA.
| | - A J Höink
- Department of Diagnostic and Interventional Radiology, University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - J Doerner
- Department of Diagnostic and Interventional Radiology, University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - D W Jordan
- Department of Radiology, University Hospitals Cleveland, Cleveland, OH, USA
- Department of Radiology, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - G Pahn
- Philips Clinical Science CT, Hamburg, Germany
| | - T Persigehl
- Department of Diagnostic and Interventional Radiology, University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - D Maintz
- Department of Diagnostic and Interventional Radiology, University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - S Haneder
- Department of Diagnostic and Interventional Radiology, University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
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Tesche C, Duguay TM, Schoepf UJ, van Assen M, De Cecco CN, Albrecht MH, Varga-Szemes A, Bayer RR, Ebersberger U, Nance JW, Thilo C. Current and future applications of CT coronary calcium assessment. Expert Rev Cardiovasc Ther 2018; 16:441-453. [PMID: 29734858 DOI: 10.1080/14779072.2018.1474347] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Computed tomographic (CT) coronary artery calcium scoring (CAC) has been validated as a well-established screening method for cardiovascular risk stratification and treatment management that is used in addition to traditional risk factors. The purpose of this review is to present an update on current and future applications of CAC. Areas covered: The topic of CAC is summarized from its introduction to current application with focus on the validation and clinical integration including cardiovascular risk prediction and outcome, cost-effectiveness, impact on downstream medical testing, and the technical advances in scanner and software technology that are shaping the future of CAC. Furthermore, this review aims to provide guidance for the appropriate clinical use of CAC. Expert commentary: CAC is a well-established screening test in preventive care that is underused in daily clinical practice. The widespread clinical implementation of CAC will be decided by future technical advances in CT image acquisition, cost-effectiveness, and reimbursement status.
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Affiliation(s)
- Christian Tesche
- a Division of Cardiovascular Imaging, Department of Radiology and Radiological Science , Medical University of South Carolina , Charleston , SC , USA.,b Department of Cardiology and Intensive Care Medicine , Heart Center Munich-Bogenhausen , Munich , Germany
| | - Taylor M Duguay
- a Division of Cardiovascular Imaging, Department of Radiology and Radiological Science , Medical University of South Carolina , Charleston , SC , USA
| | - U Joseph Schoepf
- a Division of Cardiovascular Imaging, Department of Radiology and Radiological Science , Medical University of South Carolina , Charleston , SC , USA.,c Division of Cardiology, Department of Medicine , Medical University of South Carolina , Charleston , SC , USA
| | - Marly van Assen
- a Division of Cardiovascular Imaging, Department of Radiology and Radiological Science , Medical University of South Carolina , Charleston , SC , USA.,d Center for Medical Imaging North East Netherlands , University Medical Center Groningen, University of Groningen , Groningen , The Netherlands
| | - Carlo N De Cecco
- a Division of Cardiovascular Imaging, Department of Radiology and Radiological Science , Medical University of South Carolina , Charleston , SC , USA
| | - Moritz H Albrecht
- a Division of Cardiovascular Imaging, Department of Radiology and Radiological Science , Medical University of South Carolina , Charleston , SC , USA.,e Department of Diagnostic and Interventional Radiology , University Hospital Frankfurt , Frankfurt , Germany
| | - Akos Varga-Szemes
- a Division of Cardiovascular Imaging, Department of Radiology and Radiological Science , Medical University of South Carolina , Charleston , SC , USA
| | - Richard R Bayer
- a Division of Cardiovascular Imaging, Department of Radiology and Radiological Science , Medical University of South Carolina , Charleston , SC , USA.,c Division of Cardiology, Department of Medicine , Medical University of South Carolina , Charleston , SC , USA
| | - Ullrich Ebersberger
- a Division of Cardiovascular Imaging, Department of Radiology and Radiological Science , Medical University of South Carolina , Charleston , SC , USA.,b Department of Cardiology and Intensive Care Medicine , Heart Center Munich-Bogenhausen , Munich , Germany
| | - John W Nance
- a Division of Cardiovascular Imaging, Department of Radiology and Radiological Science , Medical University of South Carolina , Charleston , SC , USA
| | - Christian Thilo
- f Department of Internal Medicine I - Cardiology , Central Hospital of Augsburg , Augsburg , Germany
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