Automatic coronary calcium scoring in chest CT using a deep neural network in direct comparison with non-contrast cardiac CT: A validation study

Meta-analysis of deep learning approaches for automated coronary artery calcium scoring: Performance and clinical utility AI in CAC scoring: A meta-analysis: AI in CAC scoring: A meta-analysis

INTRODUCTION

Manual Coronary Artery Calcium (CAC) scoring, crucial for assessing coronary artery disease risk, is time-consuming and variable. Deep learning, particularly through Convolutional Neural Networks (CNNs), promises to automate and enhance the accuracy of CAC scoring, which this study investigates.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a comprehensive literature search across PubMed, Embase, Web of Science, and IEEE databases from their inception until November 1, 2023, and selected studies that employed deep learning for automated CAC scoring. We then evaluated the quality of these studies by using the Checklist for Artificial Intelligence in Medical Imaging and the Quality Assessment of Diagnostic Accuracy Studies 2. The main metric for evaluation was Cohen's kappa statistic, indicating an agreement between deep learning models and manual scoring methods.

RESULTS

A total of 25 studies were included, with a pooled kappa statistic of 83 % (95 % CI of 79 %-87 %), indicating strong agreement between automated and manual CAC scoring. Subgroup analysis revealed performance variations based on imaging modalities and technical specifications. Sensitivity analysis confirmed the reliability of the results.

CONCLUSIONS

Deep learning models, particularly CNNs, have great potential for use in automated CAC scoring applications, potentially enhancing the efficiency and accuracy of risk assessments for coronary artery disease. Further research and standardization are required to address the major heterogeneity and performance disparities between different imaging modalities. Overall, our findings underscore the evolving role of artificial intelligence in advancing cardiac imaging and patient care.

Computed Tomography Evaluation of Coronary Atherosclerosis: The Road Travelled, and What Lies Ahead

Coronary CT angiography (CCTA) is now endorsed by all major cardiology guidelines for the investigation of chest pain and assessment for coronary artery disease (CAD) in appropriately selected patients. CAD is a leading cause of morbidity and mortality. There is extensive literature to support CCTA diagnostic and prognostic value both for stable and acute symptoms. It enables rapid and cost-effective rule-out of CAD, and permits quantification and characterization of coronary plaque and associated significance. In this comprehensive review, we detail the road traveled as CCTA evolved to include quantitative assessment of plaque stenosis and extent, characterization of plaque characteristics including high-risk features, functional assessment including fractional flow reserve-CT (FFR-CT), and CT perfusion techniques. The state of current guideline recommendations and clinical applications are reviewed, as well as future directions in the rapidly advancing field of CT technology, including photon counting and applications of artificial intelligence (AI).

Deep learning for automatic calcium detection in echocardiography

Cardiovascular diseases are the main cause of death in the world and cardiovascular imaging techniques are the mainstay of noninvasive diagnosis. Aortic stenosis is a lethal cardiac disease preceded by aortic valve calcification for several years. Data-driven tools developed with Deep Learning (DL) algorithms can process and categorize medical images data, providing fast diagnoses with considered reliability, to improve healthcare effectiveness. A systematic review of DL applications on medical images for pathologic calcium detection concluded that there are established techniques in this field, using primarily CT scans, at the expense of radiation exposure. Echocardiography is an unexplored alternative to detect calcium, but still needs technological developments. In this article, a fully automated method based on Convolutional Neural Networks (CNNs) was developed to detect Aortic Calcification in Echocardiography images, consisting of two essential processes: (1) an object detector to locate aortic valve - achieving 95% of precision and 100% of recall; and (2) a classifier to identify calcium structures in the valve - which achieved 92% of precision and 100% of recall. The outcome of this work is the possibility of automation of the detection with Echocardiography of Aortic Valve Calcification, a lethal and prevalent disease.

Revolutionizing Cardiac Imaging: A Scoping Review of Artificial Intelligence in Echocardiography, CTA, and Cardiac MRI

BACKGROUND AND INTRODUCTION

Cardiac imaging is crucial for diagnosing heart disorders. Methods like X-rays, ultrasounds, CT scans, and MRIs provide detailed anatomical and functional heart images. AI can enhance these imaging techniques with its advanced learning capabilities.

METHOD

In this scoping review, following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) Guidelines, we searched PubMed, Scopus, Web of Science, and Google Scholar using related keywords on 16 April 2024. From 3679 articles, we first screened titles and abstracts based on the initial inclusion criteria and then screened the full texts. The authors made the final selections collaboratively.

RESULT

The PRISMA chart shows that 3516 articles were initially selected for evaluation after removing duplicates. Upon reviewing titles, abstracts, and quality, 24 articles were deemed eligible for the review. The findings indicate that AI enhances image quality, speeds up imaging processes, and reduces radiation exposure with sensitivity and specificity comparable to or exceeding those of qualified radiologists or cardiologists. Further research is needed to assess AI's applicability in various types of cardiac imaging, especially in rural hospitals where access to medical doctors is limited.

CONCLUSIONS

AI improves image quality, reduces human errors and radiation exposure, and can predict cardiac events with acceptable sensitivity and specificity.

Prevalence and clinical implications of coronary artery calcium scoring on non-gated thoracic computed tomography: a systematic review and meta-analysis

OBJECTIVES

Coronary artery calcifications (CACs) indicate the presence of coronary artery disease. CAC can be found on thoracic computed tomography (CT) conducted for non-cardiac reasons. This systematic review and meta-analysis of non-gated thoracic CT aims to assess the clinical impact and prevalence of CAC.

METHODS

Online databases were searched for articles assessing prevalence, demographic characteristics, accuracy and prognosis of incidental CAC on non-gated thoracic CT. Meta-analysis was performed using a random effects model.

RESULTS

A total of 108 studies (113,406 patients) were included (38% female). Prevalence of CAC ranged from 2.7 to 100% (pooled prevalence 52%, 95% confidence interval [CI] 46-58%). Patients with CAC were older (pooled standardised mean difference 0.88, 95% CI 0.65-1.11, p < 0.001), and more likely to be male (pooled odds ratio [OR] 1.95, 95% CI 1.55-2.45, p < 0.001), with diabetes (pooled OR 2.63, 95% CI 1.95-3.54, p < 0.001), hypercholesterolaemia (pooled OR 2.28, 95% CI 1.33-3.93, p < 0.01) and hypertension (pooled OR 3.89, 95% CI 2.26-6.70, p < 0.001), but not higher body mass index or smoking. Non-gated CT assessment of CAC had excellent agreement with electrocardiogram-gated CT (pooled correlation coefficient 0.96, 95% CI 0.92-0.98, p < 0.001). In 51,582 patients, followed-up for 51.6 ± 27.4 months, patients with CAC had increased all cause mortality (pooled relative risk [RR] 2.13, 95% CI 1.57-2.90, p = 0.004) and major adverse cardiovascular events (pooled RR 2.91, 95% CI 2.26-3.93, p < 0.001). When CAC was present on CT, it was reported in between 18.6% and 93% of reports.

CONCLUSION

CAC is a common, but underreported, finding on non-gated CT with important prognostic implications.

CLINICAL RELEVANCE STATEMENT

Coronary artery calcium is an important prognostic indicator of cardiovascular disease. It can be assessed on non-gated thoracic CT and is a commonly underreported finding. This represents a significant population where there is a potential missed opportunity for lifestyle modification recommendations and preventative therapies. This study aims to highlight the importance of reporting incidental coronary artery calcium on non-gated thoracic CT.

KEY POINTS

• Coronary artery calcification is a common finding on non-gated thoracic CT and can be reliably identified compared to gated-CT. • Coronary artery calcification on thoracic CT is associated with an increased risk of all cause mortality and major adverse cardiovascsular events. • Coronary artery calcification is frequently not reported on non-gated thoracic CT.

The Role of Artificial Intelligence in Cardiac Imaging

Artificial intelligence (AI) is having a significant impact in medical imaging, advancing almost every aspect of the field, from image acquisition and postprocessing to automated image analysis with outreach toward supporting decision making. Noninvasive cardiac imaging is one of the main and most exciting fields for AI development. The aim of this review is to describe the main applications of AI in cardiac imaging, including CT and MR imaging, and provide an overview of recent advancements and available clinical applications that can improve clinical workflow, disease detection, and prognostication in cardiac disease.

Artificial intelligence in coronary artery calcium score: rationale, different approaches, and outcomes

Almost 35 years after its introduction, coronary artery calcium score (CACS) not only survived technological advances but became one of the cornerstones of contemporary cardiovascular imaging. Its simplicity and quantitative nature established it as one of the most robust approaches for atherosclerotic cardiovascular disease risk stratification in primary prevention and a powerful tool to guide therapeutic choices. Groundbreaking advances in computational models and computer power translated into a surge of artificial intelligence (AI)-based approaches directly or indirectly linked to CACS analysis. This review aims to provide essential knowledge on the AI-based techniques currently applied to CACS, setting the stage for a holistic analysis of the use of these techniques in coronary artery calcium imaging. While the focus of the review will be detailing the evidence, strengths, and limitations of end-to-end CACS algorithms in electrocardiography-gated and non-gated scans, the current role of deep-learning image reconstructions, segmentation techniques, and combined applications such as simultaneous coronary artery calcium and pulmonary nodule segmentation, will also be discussed.

Automatic thoracic aorta calcium quantification using deep learning in non-contrast ECG-gated CT images

Thoracic aorta calcium (TAC) can be assessed from cardiac computed tomography (CT) studies to improve cardiovascular risk prediction. The aim of this study was to develop a fully automatic system to detect TAC and to evaluate its performance for classifying the patients into four TAC risk categories. The method started by segmenting the thoracic aorta, combining three UNets trained with axial, sagittal and coronal CT images. Afterwards, the surrounding lesion candidates were classified using three combined convolutional neural networks (CNNs) trained with orthogonal patches. Image datasets included 1190 non-enhanced ECG-gated cardiac CT studies from a cohort of cardiovascular patients (age 57 ± 9 years, 80% men, 65% TAC > 0). In the test set (N = 119), the combination of UNets was able to successfully segment the thoracic aorta with a mean volume difference of 0.3 ± 11.7 ml (<6%) and a median Dice coefficient of 0.947. The combined CNNs accurately classified the lesion candidates and 87% of the patients (N = 104) were accurately placed in their corresponding risk categories (Kappa = 0.826, ICC = 0.9915). TAC measurement can be estimated automatically from cardiac CT images using UNets to isolate the thoracic aorta and CNNs to classify calcified lesions.

The Role of Artificial Intelligence in Coronary Calcium Scoring in Standard Cardiac Computed Tomography and Chest Computed Tomography With Different Reconstruction Kernels

PURPOSE

To assess the correlation of coronary calcium score (CS) obtained by artificial intelligence (AI) with those obtained by electrocardiography gated standard cardiac computed tomography (CCT) and nongated chest computed tomography (ChCT) with different reconstruction kernels.

PATIENTS AND METHODS

Seventy-six patients received standard CCT and ChCT simultaneously. We compared CS obtained in 4 groups: CS CCT , by the traditional method from standard CCT, 25 cm field of view, 3 mm slice thickness, and kernel filter convolution 12 (FC12); CS AICCT , by AI from the standard CCT; CS ChCTsoft , by AI from the non-gated CCT, 40 cm field of view, 3 mm slice thickness, and a soft kernel FC02; and CS ChCTsharp , by AI from CCT image with same parameters for CS ChCTsoft except for using a sharp kernel FC56. Statistical analyses included Spearman rank correlation coefficient (ρ), intraclass correlation (ICC), Bland-Altman plots, and weighted kappa analysis (κ).

RESULTS

The CS AICCT was consistent with CS CCT (ρ = 0.994 and ICC of 1.00, P < 0.001) with excellent agreement with respect to cardiovascular (CV) risk categories of the Agatston score (κ = 1.000). The correlation between CS ChCTsoft and CS ChCTsharp was good (ρ = 0.912, 0.963 and ICC = 0.929, 0.948, respectively, P < 0.001) with a tendency of underestimation (Bland-Altman mean difference and 95% upper and lower limits of agreements were 329.1 [-798.9 to 1457] and 335.3 [-651.9 to 1322], respectively). The CV risk category agreement between CS ChCTsoft and CS ChCTsharp was moderate (κ = 0.556 and 0.537, respectively).

CONCLUSIONS

There was an excellent correlation between CS CCT and CS AICCT , with excellent agreement between CV risk categories. There was also a good correlation between CS CCT and CS obtained by ChCT albeit with a tendency for underestimation and moderate accuracy in terms of CV risk assessment.

Artificial Intelligence in Coronary Artery Calcium Scoring Detection and Quantification

Coronary artery calcium (CAC) is a marker of coronary atherosclerosis, and the presence and severity of CAC have been shown to be powerful predictors of future cardiovascular events. Due to its value in risk discrimination and reclassification beyond traditional risk factors, CAC has been supported by recent guidelines, particularly for the purposes of informing shared decision-making regarding the use of preventive therapies. In addition to dedicated ECG-gated CAC scans, the presence and severity of CAC can also be accurately estimated on non-contrast chest computed tomography scans performed for other clinical indications. However, the presence of such "incidental" CAC is rarely reported. Advances in artificial intelligence have now enabled automatic CAC scoring for both cardiac and non-cardiac CT scans. Various AI approaches, from rule-based models to machine learning algorithms and deep learning, have been applied to automate CAC scoring. Convolutional neural networks, a deep learning technique, have had the most successful approach, with high agreement with manual scoring demonstrated in multiple studies. Such automated CAC measurements may enable wider and more accurate detection of CAC from non-gated CT studies, thus improving the efficiency of healthcare systems to identify and treat previously undiagnosed coronary artery disease.

Enhanced CT imaging artificial neural network coronary artery calcification score assisted diagnosis

BACKGROUND

The study of coronary artery calcification (CAC) may assist in identifying additional coronary artery problem protective factors. On the contrary side, due to the wide variety of CAC as individuals, CAC research is difficult. Due to this, evaluating data for investigation is becoming complicated.

OBJECTIVE

To use a multi-layer perceptron, we investigated the accuracy and reliability of synthetic CAC coursework or hazard classification in pre or alors chest computerized tomography (CT) of arrangements resolutions in this analysis.

method

Photographs of the chest from similar individuals as well as calcium-just and non-gated pictures were incorporated. This cut thickness ordered CT pictures (bunch A: 1 mm; bunch B: 3 mm). The CAC rating was determined utilizing calcification score picture information, and became standard for tests. While the control treatment's machine learning program was created using 170 computed tomography pictures and evaluated using 144 scans, group A's machine learning algorithm was created using 150 chest CT diagnostic tests.

RESULTS

334 external related pictures (100 μm: 117; 0.5 mm x: 117) of 117 individuals and 612 inside design organizing (1 mm: 294; mm3: 314) of 406 patients were surveyed. Pack B had 0.94, however, tests An and b had 0.90 (95% CI: 0.85-0.93) ICCs between significant learning and gold expenses (0.92-0.96). Dull Altman plots agreed well. A machine teaching approach successfully identified 71% of cases in category A is 81% of patients in section B again for cardiac risk class.

CONCLUSION

Regression risk evaluation algorithms could assist in categorizing cardiorespiratory individuals into distinct risk groups and conveniently personalize the treatments to the patient's circumstances. The models would be based on information gathered through CAC. On both 1 and 3-mm scanners, the automatic determination of a CAC value and cardiovascular events categorization that used a depth teaching approach was reliable and precise. The layer thickness of 0.5 mm on chest CT was slightly less accurate in CAC detection and risk evaluation.

Artificial intelligence in cardiac computed tomography

Artificial Intelligence (AI) is a broad discipline of computer science and engineering. Modern application of AI encompasses intelligent models and algorithms for automated data analysis and processing, data generation, and prediction with applications in visual perception, speech understanding, and language translation. AI in healthcare uses machine learning (ML) and other predictive analytical techniques to help sort through vast amounts of data and generate outputs that aid in diagnosis, clinical decision support, workflow automation, and prognostication. Coronary computed tomography angiography (CCTA) is an ideal union for these applications due to vast amounts of data generation and analysis during cardiac segmentation, coronary calcium scoring, plaque quantification, adipose tissue quantification, peri-operative planning, fractional flow reserve quantification, and cardiac event prediction. In the past 5 years, there has been an exponential increase in the number of studies exploring the use of AI for cardiac computed tomography (CT) image acquisition, de-noising, analysis, and prognosis. Beyond image processing, AI has also been applied to improve the imaging workflow in areas such as patient scheduling, urgent result notification, report generation, and report communication. In this review, we discuss algorithms applicable to AI and radiomic analysis; we then present a summary of current and emerging clinical applications of AI in cardiac CT. We conclude with AI's advantages and limitations in this new field.

Recent advances in artificial intelligence for cardiac CT: Enhancing diagnosis and prognosis prediction

Recent advances in artificial intelligence (AI) for cardiac computed tomography (CT) have shown great potential in enhancing diagnosis and prognosis prediction in patients with cardiovascular disease. Deep learning, a type of machine learning, has revolutionized radiology by enabling automatic feature extraction and learning from large datasets, particularly in image-based applications. Thus, AI-driven techniques have enabled a faster analysis of cardiac CT examinations than when they are analyzed by humans, while maintaining reproducibility. However, further research and validation are required to fully assess the diagnostic performance, radiation dose-reduction capabilities, and clinical correctness of these AI-driven techniques in cardiac CT. This review article presents recent advances of AI in the field of cardiac CT, including deep-learning-based image reconstruction, coronary artery motion correction, automatic calcium scoring, automatic epicardial fat measurement, coronary artery stenosis diagnosis, fractional flow reserve prediction, and prognosis prediction, analyzes current limitations of these techniques and discusses future challenges.

Milestones in CT: Past, Present, and Future

In 1971, the first patient CT examination by Ambrose and Hounsfield paved the way for not only volumetric imaging of the brain but of the entire body. From the initial 5-minute scan for a 180° rotation to today's 0.24-second scan for a 360° rotation, CT technology continues to reinvent itself. This article describes key historical milestones in CT technology from the earliest days of CT to the present, with a look toward the future of this essential imaging modality. After a review of the beginnings of CT and its early adoption, the technical steps taken to decrease scan times-both per image and per examination-are reviewed. Novel geometries such as electron-beam CT and dual-source CT have also been developed in the quest for ever-faster scans and better in-plane temporal resolution. The focus of the past 2 decades on radiation dose optimization and management led to changes in how exposure parameters such as tube current and tube potential are prescribed such that today, examinations are more customized to the specific patient and diagnostic task than ever before. In the mid-2000s, CT expanded its reach from gray-scale to color with the clinical introduction of dual-energy CT. Today's most recent technical innovation-photon-counting CT-offers greater capabilities in multienergy CT as well as spatial resolution as good as 125 μm. Finally, artificial intelligence is poised to impact both the creation and processing of CT images, as well as automating many tasks to provide greater accuracy and reproducibility in quantitative applications.

Workforce Crisis in Radiology in the UK and the Strategies to Deal With It: Is Artificial Intelligence the Saviour?

Radiology has seen rapid growth over the last few decades. Technological advances in equipment and computing have resulted in an explosion of new modalities and applications. However, this rapid expansion of capability and capacity has not been matched by a parallel growth in the number of radiologists. This has resulted in global shortages in the workforce, with the UK being one of the most affected countries. The UK National Health Service has been employing several conventional strategies to deal with the workforce situation with mixed success. The emergence of artificial intelligence (AI) tools that have the potential to increase efficiency and efficacy at various stages in radiology has made it possible for radiology departments to use new strategies and workflows that can offset workforce shortages to some extent. This review article discusses the current and projected radiology workforce situation in the UK and the various strategies to deal with it, including applications of AI in radiology. We highlight the benefits of AI tools in improving efficiency and patient safety. AI has a role along the patient's entire journey from the clinician requesting the appropriate radiological investigation, safe image acquisition, alerting the radiologists and clinicians about critical and life-threatening situations, cancer screening follow up, to generating meaningful radiology reports more efficiently. It has great potential in easing the workforce crisis and needs rapid adoption by radiology departments.

Artificial intelligence in coronary artery calcium measurement: Barriers and solutions for implementation into daily practice

Coronary artery calcification (CAC) measurement is a valuable predictor of cardiovascular risk. However, its measurement can be time-consuming and complex, thus driving the desire for artificial intelligence (AI)-based approaches. The aim of this review is to explore the current status of CAC volume measurement using AI-based systems for the automated prediction of cardiovascular events. We also make proposals for the implementation of these systems into clinical practice. Research to date on applying AI to CAC scoring has shown the potential for automation and risk stratification, and, overall, efficacy and a high level of agreement with categorisation by trained clinicians have been demonstrated. However, research in this field has not been uniform or directed. One contributing factor may be a lack of integration and communication between computer scientists and cardiologists. Clinicians, institutions, and organisations should work together towards applying this technology to improve processes, preserve healthcare resources, and improve patient outcomes.

Dual-Energy CT in Cardiothoracic Imaging: Current Developments

This article describes the technical principles and clinical applications of dual-energy computed tomography (DECT) in the context of cardiothoracic imaging with a focus on current developments and techniques. Since the introduction of DECT, different vendors developed distinct hard and software approaches for generating multi-energy datasets and multiple DECT applications that were developed and clinically investigated for different fields of interest. Benefits for various clinical settings, such as oncology, trauma and emergency radiology, as well as musculoskeletal and cardiovascular imaging, were recently reported in the literature. State-of-the-art applications, such as virtual monoenergetic imaging (VMI), material decomposition, perfused blood volume imaging, virtual non-contrast imaging (VNC), plaque removal, and virtual non-calcium (VNCa) imaging, can significantly improve cardiothoracic CT image workflows and have a high potential for improvement of diagnostic accuracy and patient safety.

Automated diagnosis of cardiovascular diseases from cardiac magnetic resonance imaging using deep learning models: A review

In recent years, cardiovascular diseases (CVDs) have become one of the leading causes of mortality globally. At early stages, CVDs appear with minor symptoms and progressively get worse. The majority of people experience symptoms such as exhaustion, shortness of breath, ankle swelling, fluid retention, and other symptoms when starting CVD. Coronary artery disease (CAD), arrhythmia, cardiomyopathy, congenital heart defect (CHD), mitral regurgitation, and angina are the most common CVDs. Clinical methods such as blood tests, electrocardiography (ECG) signals, and medical imaging are the most effective methods used for the detection of CVDs. Among the diagnostic methods, cardiac magnetic resonance imaging (CMRI) is increasingly used to diagnose, monitor the disease, plan treatment and predict CVDs. Coupled with all the advantages of CMR data, CVDs diagnosis is challenging for physicians as each scan has many slices of data, and the contrast of it might be low. To address these issues, deep learning (DL) techniques have been employed in the diagnosis of CVDs using CMR data, and much research is currently being conducted in this field. This review provides an overview of the studies performed in CVDs detection using CMR images and DL techniques. The introduction section examined CVDs types, diagnostic methods, and the most important medical imaging techniques. The following presents research to detect CVDs using CMR images and the most significant DL methods. Another section discussed the challenges in diagnosing CVDs from CMRI data. Next, the discussion section discusses the results of this review, and future work in CVDs diagnosis from CMR images and DL techniques are outlined. Finally, the most important findings of this study are presented in the conclusion section.

Evaluation of fully automated commercial software for Agatston calcium scoring on non-ECG-gated low-dose chest CT with different slice thickness

OBJECTIVES

To evaluate commercial deep learning-based software for fully automated coronary artery calcium (CAC) scoring on non-electrocardiogram (ECG)-gated low-dose CT (LDCT) with different slice thicknesses compared with manual ECG-gated calcium-scoring CT (CSCT).

METHODS

This retrospective study included 567 patients who underwent both LDCT and CSCT. All LDCT images were reconstructed with a 2.5-mm slice thickness (LDCT_2.5-mm), and 453 LDCT scans were reconstructed with a 1.0-mm slice thickness (LDCT_1.0-mm). Automated CAC scoring was performed on CSCT (CSCT_auto), LDCT_1.0-mm, and LDCT_2.5-mm images. The reliability of CSCT_auto, LDCT_1.0-mm, and LDCT_2.5-mm was compared with manual CSCT scoring (CSCT_manual) using intraclass correlation coefficients (ICCs) and Bland-Altman analysis. Agreement, in CAC severity category, was analyzed using weighted kappa statistics. Diagnostic performance at various Agatston score cutoffs was also calculated.

RESULTS

CSCT_auto, LDCT_1.0-mm, and LDCT_2.5-mm demonstrated excellent agreement with CSCT_manual (ICC [95% confidence interval, CI]: 1.000 [1.000, 1.000], 0.937 [0.917, 0.952], and 0.955 [0.946, 0.963], respectively). The mean difference with 95% limits of agreement was lower with LDCT_1.0-mm than with LDCT_2.5-mm (19.94 [95% CI, -244.0, 283.9] vs. 45.26 [-248.2, 338.7]). Regarding CAC severity, LDCT_1.0-mm achieved almost perfect agreement, and LDCT_2.5-mm achieved substantial agreement (kappa [95% CI]: 0.809 [0.776, 0.838], 0.776 [0.740, 0.809], respectively). Diagnostic performance for detecting Agatston score ≥ 400 was also higher with LDCT_1.0-mm than with LDCT_2.5-mm (F1 score, 0.929 vs. 0.855).

CONCLUSIONS

Fully automated CAC-scoring software with both CSCT and LDCT yielded excellent reliability and agreement with CSCT_manual. LDCT_1.0-mm yielded more accurate Agatston scoring than LDCT_2.5-mm using fully automated commercial software.

KEY POINTS

• Total Agatston scores and all vessels of CSCT_auto, LDCT_1.0-mm, and LDCT_2.5-mm demonstrated excellent agreement with CSCT_manual (all ICC > 0.85). • The diagnostic performance for detecting all Agatston score cutoffs was better with LDCT_1.0-mm than with LDCT_2.5-mm. • This automated software yielded a lower degree of underestimation compared with methods described in previous studies, and the degree of underestimation was lower with LDCT_1.0-mm than with LDCT_2.5-mm.

Artificial Intelligence for Cardiothoracic Imaging: Overview of Current and Emerging Applications

Artificial intelligence algorithms can learn by assimilating information from large datasets in order to decipher complex associations, identify previously undiscovered pathophysiological states, and construct prediction models. There has been tremendous interest and increased incorporation of artificial intelligence into various industries, including healthcare. As a result, there has been an exponential rise in the number of research articles and industry participants producing models intended for a variety of applications in medical imaging, which can be challenging to navigate for radiologists. In thoracic imaging, multiple applications are being evaluated for chest radiography and computed tomography and include applications for lung nodule evaluation and cancer imaging, quantifying diffuse lung disorders, and cardiac imaging, to name a few. This review aims to provide an overview of current clinical AI models, focusing on the most common clinical applications of AI in cardiothoracic imaging.

Artificial intelligence in coronary computed tomography angiography: Demands and solutions from a clinical perspective

Coronary computed tomography angiography (CCTA) is increasingly the cornerstone in the management of patients with chronic coronary syndromes. This fact is reflected by current guidelines, which show a fundamental shift towards non-invasive imaging - especially CCTA. The guidelines for acute and stable coronary artery disease (CAD) of the European Society of Cardiology from 2019 and 2020 emphasize this shift. However, to fulfill this new role, a broader availability in adjunct with increased robustness of data acquisition and speed of data reporting of CCTA is needed. Artificial intelligence (AI) has made enormous progress for all imaging methodologies concerning (semi)-automatic tools for data acquisition and data post-processing, with outreach toward decision support systems. Besides onco- and neuroimaging, cardiac imaging is one of the main areas of application. Most current AI developments in the scenario of cardiac imaging are related to data postprocessing. However, AI applications (including radiomics) for CCTA also should enclose data acquisition (especially the fact of dose reduction) and data interpretation (presence and extent of CAD). The main effort will be to integrate these AI-driven processes into the clinical workflow, and to combine imaging data/results with further clinical data, thus - beyond the diagnosis of CAD- enabling prediction and forecast of morbidity and mortality. Furthermore, data fusing for therapy planning (e.g., invasive angiography/TAVI planning) will be warranted. The aim of this review is to present a holistic overview of AI applications in CCTA (including radiomics) under the umbrella of clinical workflows and clinical decision-making. The review first summarizes and analyzes applications for the main role of CCTA, i.e., to non-invasively rule out stable coronary artery disease. In the second step, AI applications for additional diagnostic purposes, i.e., to improve diagnostic power (CAC = coronary artery classifications), improve differential diagnosis (CT-FFR and CT perfusion), and finally improve prognosis (again CAC plus epi- and pericardial fat analysis) are reviewed.

Fully automatic coronary calcium scoring in non-ECG-gated low-dose chest CT: comparison with ECG-gated cardiac CT

OBJECTIVES

To validate an artificial intelligence (AI)-based fully automatic coronary artery calcium (CAC) scoring system on non-electrocardiogram (ECG)-gated low-dose chest computed tomography (LDCT) using multi-institutional datasets with manual CAC scoring as the reference standard.

METHODS

This retrospective study included 452 subjects from three academic institutions, who underwent both ECG-gated calcium scoring computed tomography (CSCT) and LDCT scans. For all CSCT and LDCT scans, automatic CAC scoring (CAC_auto) was performed using AI-based software, and manual CAC scoring (CAC_man) was set as the reference standard. The reliability and agreement of CAC_auto was evaluated and compared with that of CAC_man using intraclass correlation coefficients (ICCs) and Bland-Altman plots. The reliability between CAC_auto and CAC_man for CAC severity categories was analyzed using weighted kappa (κ) statistics.

RESULTS

CAC_auto on CSCT and LDCT yielded a high ICC (0.998, 95% confidence interval (CI) 0.998-0.999 and 0.989, 95% CI 0.987-0.991, respectively) and a mean difference with 95% limits of agreement of 1.3 ± 37.1 and 0.8 ± 75.7, respectively. CAC_auto achieved excellent reliability for CAC severity (κ = 0.918-0.972) on CSCT and good to excellent but heterogenous reliability among datasets (κ = 0.748-0.924) on LDCT.

CONCLUSIONS

The application of an AI-based automatic CAC scoring software to LDCT shows good to excellent reliability in CAC score and CAC severity categorization in multi-institutional datasets; however, the reliability varies among institutions.

KEY POINTS

• AI-based automatic CAC scoring on LDCT shows excellent reliability with manual CAC scoring in multi-institutional datasets. • The reliability for CAC score-based severity categorization varies among datasets. • Automatic scoring for LDCT shows a higher false-positive rate than automatic scoring for CSCT, and most common causes of a false-positive are image noise and artifacts for both CSCT and LDCT.

Automated total and vessel-specific coronary artery calcium (CAC) quantification on chest CT: direct comparison with CAC scoring on non-contrast cardiac CT

BACKGROUND

This study aimed to evaluate the artificial intelligence (AI)-based coronary artery calcium (CAC) quantification and regional distribution of CAC on non-gated chest CT, using standard electrocardiograph (ECG)-gated CAC scoring as the reference.

METHODS

In this retrospective study, a total of 405 patients underwent non-gated chest CT and standard ECG-gated cardiac CT. An AI-based algorithm was used for automated CAC scoring on chest CT, and Agatston score on cardiac CT was manually quantified. Bland-Altman plots were used to evaluate the agreement of absolute Agatston score between the two scans at the patient and vessel levels. Linearly weighted kappa (κ) was calculated to assess the reliability of AI-based CAC risk categorization and the number of involved vessels on chest CT.

RESULTS

The AI-based algorithm showed moderate reliability for the number of involved vessels in comparison to measures on cardiac CT (κ = 0.75, 95% CI 0.70-0.79, P < 0.001) and an assignment agreement of 76%. Considerable coronary arteries with CAC were not identified with a per-vessel false-negative rate of 59.3%, 17.8%, 34.9%, and 34.7% for LM, LAD, CX, and RCA on chest CT. The leading causes for false negatives of LM were motion artifact (56.3%, 18/32) and segmentation error (43.8%, 14/32). The motion artifact was almost the only cause for false negatives of LAD (96.6%, 28/29), CX (96.7%, 29/30), and RCA (100%, 34/34). Absolute Agatston scores on chest CT were underestimated either for the patient and individual vessels except for LAD (median difference: - 12.5, - 11.3, - 5.6, - 18.6 for total, LM, CX, and RCA, all P < 0.01; - 2.5 for LAD, P = 0.18). AI-based total Agatston score yielded good reliability for risk categorization (weighted κ 0.86, P < 0.001) and an assignment agreement of 86.7% on chest CT, with a per-patient false-negative rate of 15.2% (28/184) and false-positive rate of 0.5% (1/221) respectively.

CONCLUSIONS

AI-based per-patient CAC quantification on non-gated chest CT achieved a good agreement with dedicated ECG-gated CAC scoring overall and highly reliable CVD risk categorization, despite a slight but significant underestimation. However, it is challenging to evaluate the regional distribution of CAC without ECG-synchronization.

Application of AI in cardiovascular multimodality imaging

Technical advances in artificial intelligence (AI) in cardiac imaging are rapidly improving the reproducibility of this approach and the possibility to reduce time necessary to generate a report. In cardiac computed tomography angiography (CCTA) the main application of AI in clinical practice is focused on detection of stenosis, characterization of coronary plaques, and detection of myocardial ischemia. In cardiac magnetic resonance (CMR) the application of AI is focused on post-processing and particularly on the segmentation of cardiac chambers during late gadolinium enhancement. In echocardiography, the application of AI is focused on segmentation of cardiac chambers and is helpful for valvular function and wall motion abnormalities. The common thread represented by all of these techniques aims to shorten the time of interpretation without loss of information compared to the standard approach. In this review we provide an overview of AI applications in multimodality cardiac imaging.

Artificial Intelligence in Coronary CT Angiography: Current Status and Future Prospects

Coronary heart disease (CHD) is the leading cause of mortality in the world. Early detection and treatment of CHD are crucial. Currently, coronary CT angiography (CCTA) has been the prior choice for CHD screening and diagnosis, but it cannot meet the clinical needs in terms of examination quality, the accuracy of reporting, and the accuracy of prognosis analysis. In recent years, artificial intelligence (AI) has developed rapidly in the field of medicine; it played a key role in auxiliary diagnosis, disease mechanism analysis, and prognosis assessment, including a series of studies related to CHD. In this article, the application and research status of AI in CCTA were summarized and the prospects of this field were also described.

Fully Automated Artery-Specific Calcium Scoring Based on Machine Learning in Low-Dose Computed Tomography Screening

PURPOSE

 Evaluation of machine learning-based fully automated artery-specific coronary artery calcium (CAC) scoring software, using semi-automated software as a reference.

METHODS

 A total of 505 patients underwent non-contrast-enhanced calcium scoring computed tomography (CSCT). Automated, machine learning-based software quantified the Agatston score (AS), volume score (VS), and mass score (MS) of each coronary artery [right coronary artery (RCA), left main (LM), circumflex (CX) and left anterior descending (LAD)]. Identified CAC of readers who annotated the data with semi-automated software served as a reference standard. Statistics included comparisons of evaluation time, agreement of identified CAC, and comparisons of the AS, VS, and MS of the reference standard and the fully automated algorithm.

RESULTS

 The machine learning-based software correlated strongly with the reference standard for the AS, VS, and MS (Spearman's rho > 0.969) (p < 0.001), with excellent agreement (ICC > 0.919) (p < 0.001). The mean assessment time of the reference standard was 59 seconds (IQR 39-140) and that of the automated algorithm was 5.9 seconds (IQR 3.9-16) (p < 0.001). The Bland-Altman plots mean difference and 1.96 upper and lower limits of agreement for all arteries combined were: AS 0.996 (1.33 to 0.74), VS 0.995 (1.40 to 0.71), and MS 0.995 (1.35 to 0.74). The mean bias was minimal: 0.964-1.0429. Risk class assignment showed high accuracy for the AS in total (weighed κ = 0.99) and for each individual artery (κ = 0.96-0.99) with corresponding correct risk group assignment in 497 of 505 patients (98.4 %).

CONCLUSION

 The fully automated artery-specific coronary calcium scoring algorithm is a time-saving procedure and shows excellent correlation and agreement compared with the clinically established semi-automated approach.

KEY POINTS

  · Very high correlation and agreement between fully automatic and semi-automatic calcium scoring software.. · Less time-consuming than conventional semi-automatic methods.. · Excellent tool for artery-specific calcium scoring in a clinical setting..

CITATION FORMAT

· Winkelmann MT, Jacoby J, Schwemmer C et al. Fully Automated Artery-Specific Calcium Scoring Based on Machine Learning in Low-Dose Computed Tomography Screening. Fortschr Röntgenstr 2022; DOI: 10.1055/a-1717-2703.

Performance of artificial intelligence-based coronary artery calcium scoring in non-gated chest CT

OBJECTIVES

To evaluate the risk category performance of artificial intelligence-based coronary artery calcium score (AI-CACS) software used in non-gated chest computed tomography (CT) on three types of CT machines, considering the manual method as the standard.

METHODS

A total of 901 patients who underwent both chest CT and electrocardiogram (ECG)-gated non-contrast-enhanced cardiac CT with the same equipment within a 3-month period were enrolled in the study. AI-CACS software was based on a deep learning algorithm and was trained on multi-vendor, multi-scanner, and multi-hospital anonymized data from the chest CT database. The AI-CACS was automatically obtained from chest CT data by the AI-CACS software, while the manual CACS was obtained from cardiac CT data by the manual method. The correlation of the AI-CACS and manual CACS, concordance rate and kappa value of the risk categories determined by the two methods were calculated. The chi-square test was used to evaluate the differences in risk categories among the three types of CT machines from different manufacturers. The risk category performance of the AI-CACS for dichotomous risk categories bounded by 0, 100 and 400 was assessed.

RESULTS

The correlation of the AI-CACS with the manual CACS was ρ = 0.893 (p < 0.001). The Bland-Altman plot (AI-CACS minus manual CACS) showed a mean difference of -27.2 and 95% limits of agreement of -290.0 to 235.6. The agreement of risk categories for the CACS was kappa (κ) = 0.679 (p < 0.001), and the concordance rate was 80.6%. The risk categories determined by the AI-CACS software on three types of CT machines were not significantly different (p = 0.7543). As dichotomous risk categories bounded by 0, 100 and 400, the accuracy, kappa value, and area under the curve of the AI-CACS were 88.6% vs. 92.9% vs. 97.9%, 0.77 vs. 0.77 vs. 0.83, and 0.885 vs. 0.964 vs. 0.981, respectively.

CONCLUSIONS

There was good correlation and agreement between the AI-CACS and manual CACS in terms of the risk category. It is feasible to obtain the CACS using AI software based on non-gated chest CT data in a short time without increasing the radiation dose or economic burden. The AI-CACS software algorithm has good clinical universality and can be applied to CT machines from different manufacturers.