1
|
Sliwicka O, Sechopoulos I, Baggiano A, Pontone G, Nijveldt R, Habets J. Dynamic myocardial CT perfusion imaging-state of the art. Eur Radiol 2023; 33:5509-5525. [PMID: 36997751 PMCID: PMC10326111 DOI: 10.1007/s00330-023-09550-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/02/2023] [Accepted: 02/22/2023] [Indexed: 04/01/2023]
Abstract
In patients with suspected coronary artery disease (CAD), dynamic myocardial computed tomography perfusion (CTP) imaging combined with coronary CT angiography (CTA) has become a comprehensive diagnostic examination technique resulting in both anatomical and quantitative functional information on myocardial blood flow, and the presence and grading of stenosis. Recently, CTP imaging has been proven to have good diagnostic accuracy for detecting myocardial ischemia, comparable to stress magnetic resonance imaging and positron emission tomography perfusion, while being superior to single photon emission computed tomography. Dynamic CTP accompanied by coronary CTA can serve as a gatekeeper for invasive workup, as it reduces unnecessary diagnostic invasive coronary angiography. Dynamic CTP also has good prognostic value for the prediction of major adverse cardiovascular events. In this article, we will provide an overview of dynamic CTP, including the basics of coronary blood flow physiology, applications and technical aspects including protocols, image acquisition and reconstruction, future perspectives, and scientific challenges. KEY POINTS: • Stress dynamic myocardial CT perfusion combined with coronary CTA is a comprehensive diagnostic examination technique resulting in both anatomical and quantitative functional information. • Dynamic CTP imaging has good diagnostic accuracy for detecting myocardial ischemia comparable to stress MRI and PET perfusion. • Dynamic CTP accompanied by coronary CTA may serve as a gatekeeper for invasive workup and can guide treatment in obstructive coronary artery disease.
Collapse
Affiliation(s)
- Olga Sliwicka
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Ioannis Sechopoulos
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Andrea Baggiano
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Gianluca Pontone
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Robin Nijveldt
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jesse Habets
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Department of Radiology and Nuclear Medicine, Haaglanden Medical Center, The Hague, The Netherlands
| |
Collapse
|
2
|
Abstract
Cardiac imaging has a pivotal role in the prevention, diagnosis and treatment of ischaemic heart disease. SPECT is most commonly used for clinical myocardial perfusion imaging, whereas PET is the clinical reference standard for the quantification of myocardial perfusion. MRI does not involve exposure to ionizing radiation, similar to echocardiography, which can be performed at the bedside. CT perfusion imaging is not frequently used but CT offers coronary angiography data, and invasive catheter-based methods can measure coronary flow and pressure. Technical improvements to the quantification of pathophysiological parameters of myocardial ischaemia can be achieved. Clinical consensus recommendations on the appropriateness of each technique were derived following a European quantitative cardiac imaging meeting and using a real-time Delphi process. SPECT using new detectors allows the quantification of myocardial blood flow and is now also suited to patients with a high BMI. PET is well suited to patients with multivessel disease to confirm or exclude balanced ischaemia. MRI allows the evaluation of patients with complex disease who would benefit from imaging of function and fibrosis in addition to perfusion. Echocardiography remains the preferred technique for assessing ischaemia in bedside situations, whereas CT has the greatest value for combined quantification of stenosis and characterization of atherosclerosis in relation to myocardial ischaemia. In patients with a high probability of needing invasive treatment, invasive coronary flow and pressure measurement is well suited to guide treatment decisions. In this Consensus Statement, we summarize the strengths and weaknesses as well as the future technological potential of each imaging modality.
Collapse
|
3
|
Alessio AM, Bindschadler M, Busey JM, Shuman WP, Caldwell JH, Branch KR. Accuracy of Myocardial Blood Flow Estimation From Dynamic Contrast-Enhanced Cardiac CT Compared With PET. Circ Cardiovasc Imaging 2019; 12:e008323. [PMID: 31195817 DOI: 10.1161/circimaging.118.008323] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Background The accuracy of absolute myocardial blood flow (MBF) from dynamic contrast-enhanced cardiac computed tomography acquisitions has not been fully characterized. We evaluate computed tomography (CT) compared with rubidium-82 positron emission tomography (PET) MBF estimates in a high-risk population. Methods In a prospective trial, patients receiving clinically indicated rubidium-82 PET exams were recruited to receive a dynamic contrast-enhanced cardiac computed tomography exam. The CT protocol included a rest and stress dynamic portion each acquiring 12 to 18 cardiac-gated frames. The global MBF was estimated from the PET and CT exam. Results Thirty-four patients referred for cardiac rest-stress PET were recruited. Of the 68 dynamic contrast-enhanced cardiac computed tomography scans, 5 were excluded because of injection errors or mismatched hemodynamics. The CT-derived global MBF was highly correlated with the PET MBF (r=0.92; P<0.001) with a mean difference of 0.7±26.4%. The CT MBF estimates were within 20% of PET estimates ( P<0.02) with a mean of (1) MBF for resting flow of PET versus CT of 0.9±0.3 versus 1.0±0.2 mL/min per gram and (2) MBF for stress flow of 2.1±0.7 versus 2.0±0.8 mL/min per gram. Myocardial flow reserve was -14±28% underestimated with CT (PET versus CT myocardial flow reserve, 2.5±0.6 versus 2.2±0.6). The proposed rest+stress+computed tomography angiography protocol had a dose length product of 598±76 mGy×cm resulting in an approximate effective dose of 8.4±1.1 mSv. Conclusions In a high-risk clinical population, a clinically practical dynamic contrast-enhanced cardiac computed tomography provided unbiased MBF estimates within 20% of rubidium-82 PET. Although unbiased, the CT estimates contain substantial variance with an standard error of the estimate of 0.44 mL/min per gram. Myocardial flow reserve estimation was not as accurate as individual MBF estimates.
Collapse
Affiliation(s)
- Adam M Alessio
- Department of Radiology (A.M.A., M.B., J.M.B., W.P.S., J.H.C.), University of Washington.,Computational Mathematics, Biomedical Engineering, and Radiology, Michigan State University (A.M.A.)
| | - Michael Bindschadler
- Department of Radiology (A.M.A., M.B., J.M.B., W.P.S., J.H.C.), University of Washington
| | - Janet M Busey
- Department of Radiology (A.M.A., M.B., J.M.B., W.P.S., J.H.C.), University of Washington
| | - William P Shuman
- Department of Radiology (A.M.A., M.B., J.M.B., W.P.S., J.H.C.), University of Washington
| | - James H Caldwell
- Department of Radiology (A.M.A., M.B., J.M.B., W.P.S., J.H.C.), University of Washington.,Division of Cardiology, Department of Medicine (J.H.C., K.R.B.), University of Washington
| | - Kelley R Branch
- Division of Cardiology, Department of Medicine (J.H.C., K.R.B.), University of Washington
| |
Collapse
|