Incremental value of adenosine-induced stress myocardial perfusion imaging with dual-source CT at cardiac CT angiography

STress computed tomogRaphy perfusion and stress cArdiac magnetic resonance for ThE manaGement of suspected or known coronarY artery disease: resources and outcomes impact

BACKGROUND

The aim of this study is to describe resources and outcomes of coronary computed tomography angiography plus Stress CT perfusion (CCTA ​+ ​Stress-CTP) and stress cardiovascular magnetic resonance (Stress-CMR) in symptomatic patients with suspected or known CAD.

METHODS

Six hundred and twenty-four consecutive symptomatic patients with intermediate to high-risk pretest likelihood for CAD or previous history of revascularization referred to our hospital for clinically indicated CCTA ​+ ​Stress-CTP or Stress-CMR were enrolled. Stress-CTP scans were performed in 223 patients while 401 patients performed Stress-CMR. Patient follow-up was performed at 1 year after index test performance. Endpoints were all cardiac events, as a combined endpoint of revascularization, non-fatal MI and death, and hard cardiac events, as combined endpoint of non-fatal MI and death.

RESULTS

Twenty-nine percent of patients who underwent CCTA ​+ ​Stress-CTP received revascularization, 7% of subjects assessed with Stress-CMR were treated invasively, and a low number of non-fatal MI and death was observed with both strategies (hard events in 0.4% of patients that had CCTA ​+ ​Stress-CTP as index test, and in 3% of patients evaluated with Stress-CMR). According to the predefined endpoints, CCTA ​+ ​Stress-CTP group showed high rate of all cardiac events and low rate of hard cardiac events, respectively. The cumulative costs were 1970 ​± ​2506 Euro and 733 ​± ​1418 Euro for the CCTA ​+ ​Stress-CTP group and Stress-CMR group, respectively.

CONCLUSIONS

The use of CCTA ​+ ​Stress-CTP strategy was associated with high referral to revascularization but with a favourable trend in terms of hard cardiac events and diagnostic yield in identifying individuals at lower risk of adverse events despite the presence of CAD.

Outcomes of Functional Testing Versus Invasive Cardiac Catheterization for the Evaluation of Intermediate Severity Coronary Stenosis Detected on Cardiac Computed Tomography Angiography

INTRODUCTION

The aim of this study was to evaluate the effectiveness of functional testing in comparison to invasive coronary angiography (ICA) among acute chest pain patients whose first diagnostic modality was a coronary computed tomography angiogram (CCTA) and were found to have intermediate coronary stenosis, defined as 50%-70% luminal stenosis.

METHODS

We conducted a retrospective review of 4763 acute chest pain patients ≥18 years old who received a CCTA as the initial diagnostic modality. Of these, 118 patients met enrollment criteria and proceeded to either stress test (80/118) or directly to ICA (38/118). The primary outcome was 30-day major adverse cardiac event, consisting of acute myocardial infarction, urgent revascularization, or death.

RESULTS

There was no difference in 30-day major adverse cardiac event among patients who underwent initial stress testing versus directly referred to ICA (0% vs. 2.6%, P = 0.322) following CCTA. The rate of revascularization without acute myocardial infarction was significantly higher among those who underwent ICA versus stress test [36.8% vs. 3.8%, P < 0.0001; adjusted odds ratio: 9.6, 95% confidence interval, 1.8-49.6]. Patients who underwent ICA had a higher rate of catheterization without revascularization within 30 days of the index admission in comparison to those who underwent initial stress testing (55.3% vs. 12.5%, P < 0.0001; adjusted odds ratio: 26.7, 95% confidence interval, 6.6-109.5).

CONCLUSION

Among patients with intermediate coronary stenosis on CCTA, a functional stress test compared with ICA may prevent unnecessary revascularization and improve cardiac catheterization yield without negatively affecting the 30-day patient safety profile.

The Feasibility, Tolerability, Safety, and Accuracy of Low-radiation Dynamic Computed Tomography Myocardial Perfusion Imaging With Regadenoson Compared With Single-photon Emission Computed Tomography

OBJECTIVES

Computed tomography (CT) myocardial perfusion imaging (CT-MPI) with hyperemia induced by regadenoson was evaluated for the detection of myocardial ischemia, safety, relative radiation exposure, and patient experience compared with single-photon emission computed tomography (SPECT) imaging.

MATERIALS AND METHODS

Twenty-four patients (66.5 y, 29% male) who had undergone clinically indicated SPECT imaging and provided written informed consent were included in this phase II, IRB-approved, and FDA-approved clinical trial. All patients underwent coronary CT angiography and CT-MPI with hyperemia induced by the intravenous administration of regadenoson (0.4 mg/5 mL). Patient experience and findings on CT-MPI images were compared to SPECT imaging.

RESULTS

Patient experience and safety were similar between CT-MPI and SPECT procedures and no serious adverse events due to the administration of regadenoson occurred. SPECT resulted in a higher number of mild adverse events than CT-MPI. Patient radiation exposure was similar during the combined coronary computed tomography angiography and CT-MPI (4.4 [2.7] mSv) and SPECT imaging (5.6 [1.7]  mSv) (P-value 0.401) procedures. Using SPECT as the reference standard, CT-MPI analysis showed a sensitivity of 58.3% (95% confidence interval [CI]: 27.7-84.8), a specificity of 100% (95% CI: 73.5-100), and an accuracy of 79.1% (95% CI: 57.9-92.87). Low apparent sensitivity occurred when the SPECT defects were small and highly suspicious for artifacts.

CONCLUSIONS

This study demonstrated that CT-MPI is safe, well tolerated, and can be performed with comparable radiation exposure to SPECT. CT-MPI has the benefit of providing both complete anatomic coronary evaluation and assessment of myocardial perfusion.

Computed tomography of coronary artery atherosclerosis: A review

Coronary artery atherosclerosis resulting in ischemic cardiac disease is the leading cause of mortality in the United States. In symptomatic patients, invasive diagnostic methods like catheter angiography, intravascular ultrasound, or vascular endoscopy may be used. However, for primary prevention of atherosclerotic coronary artery disease in asymptomatic patients, non-invasive methods are more commonly utilized like stress imaging, single-photon emission computed tomography (SPECT) and coronary artery calcification scoring. Coronary computed tomographic angiography (CCTA) is an excellent diagnostic tool for detection of coronary artery plaque and ability to identify resultant stenoses with an excellent negative predictive value which can potentially result in optimal exclusion of the presence of coronary artery disease. Long term follow up after a negative CCTA has repeatedly demonstrated very low incidence of future adverse coronary events, attesting its predictive value. CCTA based management is associated with improved CAD outcome in stable angina. Coronary CTA is valuable in acute chest pain evaluation in the emergency department helping in better triage. CT perfusion and CT-FFR are both very promising tools for assessment of hemodynamic significance of coronary artery stenosis.

CT Assessment of Myocardial Perfusion and Fractional Flow Reserve in Coronary Artery Disease: A Review of Current Clinical Evidence and Recent Developments

Coronary computed tomography angiography (CCTA) is routinely used for anatomical assessment of coronary artery disease (CAD). However, invasive measurement of fractional flow reserve (FFR) is the current gold standard for the diagnosis of hemodynamically significant CAD. CT-derived FFRCT and CT perfusion are two emerging techniques that can provide a functional assessment of CAD for risk stratification and clinical decision making. Several clinical studies have shown that the diagnostic performance of concomitant CCTA and functional CT assessment for detecting hemodynamically significant CAD is at least non-inferior to that of other routinely used imaging modalities. This article aims to review the current clinical evidence and recent developments in functional CT techniques.

CT and MR Imaging Findings of Structural Heart Diseases Associated with Sudden Cardiac Death

급성 심장사는 증상이 시작된 후 한 시간 이내에 발생하는 심장 원인으로 인한 사망이다. 급성 심장사의 원인은 주로 부정맥이지만 동반할 수 있는 기저 심질환들을 사전에 진단하는 것은 장기적 위험을 예측하는 데 중요하다. 심장 CT와 심장 MR은 구조적 심질환을 진단하고 평가하는데 중요한 정보를 제공하여 급성 심장사의 위험을 예측하고 대비할 수 있게 한다. 따라서 임상적으로 중요한 급성 심장사의 위험을 증가시키는 다양한 원인과 영상 소견의 중요성에 대하여 중점적으로 살펴보고자 한다.

Comparison of automated beam hardening correction (ABHC) algorithms for myocardial perfusion imaging using computed tomography

PURPOSE

Myocardial perfusion imaging using computed tomography (MPI-CT) and coronary CT angiography (CTA) have the potential to make CT an ideal noninvasive imaging gatekeeper exam for invasive coronary angiography. However, beam hardening can prevent accurate blood flow estimation in dynamic MPI-CT and can create artifacts that resemble flow deficits in single-shot MPI-CT. In this work, we compare four automatic beam hardening correction algorithms (ABHCs) applied to CT images, for their ability to produce accurate single images of contrast and accurate MPI flow maps using images from conventional CT systems, without energy sensitivity.

METHODS

Previously, we reported a method, herein called ABHC-1, where we iteratively optimized a cost function sensitive to beam hardening artifacts in MPI-CT images and used a low order polynomial correction on projections of segmentation-processed CT images. Here, we report results from two new algorithms with higher order polynomial corrections, ABHC-2 and ABHC-3 (with three and seven free parameters, respectively), having potentially better correction but likely reduced estimability. Additionally, we compared results to an algorithm reported by others in the literature (ABHC-NH). Comparisons were made on a digital static phantom with simulated water, bone, and iodine regions; on a digital dynamic anthropomorphic phantom, with simulated blood flow; and on preclinical porcine experiments. We obtained CT images on a prototype spectral detector CT (Philips Healthcare) scanner that provided both conventional and virtual keV images, allowing us to quantitatively compare corrected CT images to virtual keV images. To test these methods' parameter optimization sensitivity to noise, we evaluated results on images obtained using different mAs.

RESULTS

In images of the static phantom, ABHC-2 reduced beam hardening artifacts better than our previous ABHC-1 algorithm, giving artifacts smaller than 1.8 HU, even in the presence of high noise which should affect parameter optimization. Taken together, the quality of static phantom results ordered ABHC-2> ABHC-3> ABHC-1>> ABHC-NH. In an anthropomorphic MPI-CT simulator with homogeneous myocardial blood flow of 100 ml⋅min-1 ⋅100 g-1 , blood flow estimation results were 122 ± 24 (FBP), 135 ± 24 (ABHC-NH), 104 ± 14 (ABHC-1), 100 ± 12 (ABHC-2), and 108 ± 18 (ABHC-3) ml⋅min-1 ⋅100 g-1 , showing ABHC-2 as a clear winner. Visual and quantitative evaluations showed much improved homogeneity of myocardial flow with ABHC-2, nearly eliminating substantial artifacts in uncorrected flow maps which could be misconstrued as flow deficits. ABHC-2 performed universally better than ABHC-1, ABHC-3, and ABHC-NH in simulations with different acquisitions (varying noise and kVp values). In the presence of a simulated flow deficit, all ABHC methods retained the flow deficit, and ABHC-2 gave the most accurate flow ratio and homogeneity. ABHC-3 corrected phantom flow values were slightly better than ABHC-2, in noiseless images, suggesting that reduced quality in noisy images was due to reduced estimability. In an experiment with a pig expected to have uniform flow, ABHC-2 applied to conventional images improved flow maps to compare favorably to those from 70keV images.

CONCLUSION

The automated algorithm can be used with different parametric BH correction models. ABHC-2 improved MPI-CT blood flow estimation as compared to other approaches and was robust to noisy images. In simulation and preclinical experiments, ABHC-2 gave results approaching gold standard 70 keV measurements.

[Possibilities of Stress Computed Tomography Myocardial Perfusion Imaging in the Diagnosis of Ischemic Heart Disease]

Computed tomography angiography (CT-angiography, CTA) allows noninvasive visualization of coronary arteries (CA). This method is highly sensitive in detecting coronary atherosclerosis. However, standard CTA does not allow evaluation of the hemodynamic significance of found CA stenoses, which requires additional functional tests for detection of myocardial ischemia. This review focuses on possibilities of clinical use, limitations, technical aspects, and prospects of a combination of CT-angiography and CT myocardial perfusion imaging in diagnostics of ischemic heart disease.

Low-dose CT perfusion with combined use of CTP and CTP-derived coronary CT angiography at 70 kVp: validation with invasive fractional flow reserve

OBJECTIVES

To investigate the diagnostic performance of 70-kVp stress dynamic myocardial CT perfusion (CTP) as a low-dose, one-stop cardiac CT examination in clinical application.

MATERIALS AND METHODS

Consecutive symptomatic patients were prospectively recruited and scanned with stress dynamic myocardial CTP. The CTP phase with the best enhancement of the coronary arteries was selected and extracted as the CTP-derived single-phase coronary CT angiography (SP-CTA). The diagnostic performance of CTP and CTP+SP-CTA for functionally significant CAD was assessed. Invasive coronary angiography and fractional flow reserve were used as the reference standard for the myocardial ischemia evaluation.

RESULTS

In total, 71 patients (43 men and 28 women; 63.6 ± 8.8 years old) underwent the stress dynamic myocardial CTP; 63 vessels (36.2%) from 42 of the patients (59.2%) were identified as causing ischemia. On a per-vessel basis, the sensitivity, specificity, PPV, NPV, and diagnostic accuracy for CTP and CTP+SP-CTA were 77.8%, 93.7%, 87.5%, 88.1%, and 87.9% and 84.1%, 93.7%, 88.3%, 91.2%, and 90.2%, respectively. The area under the curve (AUC) of CTP+SP-CTA (AUC = 0.963; 95%CI, 0.938-0.989) was significantly superior to that of CTP (AUC = 0.922; 95%CI, 0.880-0.964) and that of SP-CTA (AUC = 0.833; 95%CI, 0.765-0.900) alone (all p < 0.01). The mean radiation dose of the CTP examination was 3.8 ± 1.4 mSv.

CONCLUSION

CTP-derived SP-CTA improved the diagnostic value of CTP. With a promising performance of myocardial ischemia detection and low radiation dose, the innovative low-dose, one-stop CTP examination is clinically feasible for patients who need to receive a myocardial perfusion assessment.

KEY POINTS

• Myocardial CTP performed well in the evaluation of hemodynamically significant CAD. • CTP-derived single-phase CCTA improved the diagnostic value of CTP. • The combined use of low-dose CTP and CTP-derived CCTA at 70 kVp is clinically feasible for CAD patients who need to receive a myocardial perfusion assessment.

Multimodality imaging in chronic heart failure

The prevalence of heart failure (HF) is approximately 1-2% of the adult population in developed countries, rising to  ≥ 10% among people over 70. The common symptoms of HF include shortness of breath, ankle swelling and fatigue, determined by a reduced cardiac output. Multimodality imaging is crucial to define HF etiology, determine prognosis and guiding tailored treatments. Echocardiography is the most widely used imaging modality and maintains a pivotal role in the initial diagnostic work-up and in the follow-up of HF patients. Cardiac magnetic resonance (CMR) may support the morpho-functional assessment provided by echocardiography when the acoustic window is limited or a gold standard evaluation is required. Furthermore, CMR is frequently used due to the unmatched capability to characterize myocardial structure. Coronary computed tomography angiography has become the non-invasive imaging of choice to diagnose or rule-out coronary artery disease, acquiring remarkable importance in the management of HF patients. Moreover, emerging capabilities of CT-based tissue characterization may be useful, especially when CMR is contraindicated. Finally, chest CT may contribute to precisely define the framework of HF patients, revealing new insight about cardiopulmonary pathophysiological interactions with potential high prognostic value.

Diagnostic Accuracy of Perfusional Computed Tomography in Moderate Coronary Stenosis: Comparison With Fractional Flow Reserve

Coronary computed tomography with myocardial perfusion imaging (CCTA-MPI) provides data on coronary anatomy and perfusion and may be useful in the assessment of ischemic coronary artery disease (CAD). Management of angiographically intermediate coronary lesions is challenging, and coronary fractional flow reserve (FFR) evaluation is recommended to assess whether these lesions are functionally significant. Our aim was to evaluate the diagnostic accuracy of CCTA-MPI in patients with stable CAD and at least 1 angiographically intermediate coronary lesion submitted to FFR. In this single-center prospective study, patients with stable CAD and at least 1 moderate coronary stenosis (50%-70% by visual estimation) were referred for CCTA-MPI (64-row multidetector) assessment before coronary FFR evaluation. Patients with severe coronary obstructions (≥70%) were excluded. The significance level adopted for all tests was 5%. Twenty-eight patients (mean age 60 ± SD years, 54% women) with 33 intermediate coronary obstructions were enrolled. Ten patients (30%) had functionally significant coronary obstructions characterized by FFR ≤0.8. The sensitivity, specificity, and accuracy of CCTA-MPI for the detection of functionally significant coronary obstructions were 30%, 100%, and 78.8%, respectively. CCTA-MPI positive predictive value was 100%, whereas negative predictive value was 76.7%. Correlation coefficient between tests was 0.48 (P = 0.005). On a novel approach to evaluate intermediate coronary lesions, accuracy of CCTA-MPI was 78.8%. The positive predictive value of an abnormal CCTA-MPI on this population was 100%, suggesting that CCTA-MPI may have a role in the assessment of patients with anatomically identified intermediate coronary lesions.

Evaluation of Myocardial Perfusion by Computed Tomography - Principles, Technical Background and Recommendations

Coronary computed tomography angiography (CCTA) has gained a prominent role in the evaluation of coronary artery disease. However, its anatomical nature does not allow the evaluation of the functional repercussion of coronary obstructions. It has been made possible to evaluate Myocardial computed tomography perfusion (Myocardial CTP) recently, based on myocardial contrast changes related to coronary stenoses. Several studies have validated this technique against the anatomical reference method (cardiac catheterization) and other functional methods, including myocardial perfusion scintigraphy and fractional flow reserve. The Myocardial CTP is performed in conjunction with the CCTA, a combined analysis of anatomy and function. The stress phase (with assessment of myocardial perfusion) can be performed before or after the resting phase (assessment of resting perfusion and coronary arteries), and different acquisition parameters are proposed according to the protocol and type of equipment used. Stressors used are based on coronary vasodilation (e.g. dipyridamole, adenosine). Image interpretation, similar to other perfusion assessment methods, is based on the identification and quantification of myocardial perfusion defects. The integration of both perfusion and anatomical findings is fundamental for the examination interpretation algorithm, allowing to define if the stenoses identified are hemodynamically significant and may be related to myocardial ischemia.

Hemodynamic impact of coronary stenosis using computed tomography: comparison between noninvasive fractional flow reserve and 3D fusion of coronary angiography with stress myocardial perfusion

Vasodilator-stress CT perfusion imaging in addition to CT coronary angiography (CTCA) may provide a single-test alternative to nuclear stress testing, commonly used to assess hemodynamic significance of stenosis. Another alternative is fractional flow reserve (FFR) calculated from cardiac CT images. We studied the concordance between these two approaches and their relationship to outcomes. We prospectively studied 150 patients with chest pain, who underwent CTCA and regadenoson CT. CTCA images were interpreted for presence and severity of stenosis. Fused 3D displays of subendocardial X-ray attenuation with coronary arteries were created to detect stress perfusion defects (SPD) in each coronary territory. In patients with stenosis > 25%, CT-FFR was quantified. Significant stenosis was determined by: (1) combination of stenosis > 50% with an SPD, (2) CT-FFR ≤ 0.80. Patients were followed-up for 36 ± 25 months for death, myocardial infarction or revascularization. After excluding patients with normal arteries and technical/quality issues, in final analysis of 76 patients, CTCA depicted stenosis > 70% in 13/224 arteries, 50-70% in 24, and < 50% in 187. CT-FFR ≤ 0.80 was found in 41/224 arteries, and combination of SPD with > 50% stenosis in 31/224 arteries. Inter-technique agreement was 89%. Despite high incidence of abnormal CT-FFR (30/76 patients), only 7 patients experienced adverse outcomes; 6/7 also had SPDs. Only 1/9 patients with CT-FFR ≤ 0.80 but normal perfusion had an event. Fusion of CTCA and stress perfusion can help determine the hemodynamic impact of stenosis in one test, in good agreement with CT-FFR. Adding stress CT perfusion analysis may help risk-stratify patients with abnormal CT-FFR.

CT Myocardial Perfusion Imaging: A New Frontier in Cardiac Imaging

The past two decades have witnessed rapid and remarkable technical improvement of multidetector computed tomography (CT) in both image quality and diagnostic accuracy. These improvements include higher temporal resolution, high-definition and wider detectors, the introduction of dual-source and dual-energy scanners, and advanced postprocessing. Current new generation multidetector row (≥64 slices) CT systems allow an accurate and reliable assessment of both coronary epicardial stenosis and myocardial CT perfusion (CTP) imaging at rest and during pharmacologic stress in the same examination. This novel application makes CT the unique noninvasive "one-stop-shop" method for a comprehensive assessment of both anatomical coronary atherosclerosis and its physiological consequences. Myocardial CTP imaging can be performed with different approaches such as static arterial first-pass imaging, and dynamic CTP imaging, with their own advantages and disadvantages. Static CTP can be performed using single-energy or dual-energy CT, employing qualitative or semiquantitative analysis. In addition, dynamic CTP can obtain quantitative data of myocardial blood flow and coronary flow reserve. The purpose of this review was to summarize all available evidence about the emerging role of myocardial CTP to identify ischemia-associated lesions, focusing on technical considerations, clinical applications, strengths, limitations, and the more promising future fields of interest in the broad spectra of ischemic heart disease.

Diagnostic performance of static single-scan stress perfusion cardiac computed tomography in detecting hemodynamically significant coronary artery stenosis: a comparison with combined invasive coronary angiography and cardiovascular magnetic resonance-myocardial perfusion imaging

Background Non-invasive anatomical and physiological evaluations of coronary artery disease (CAD) may be obtained with static single-scan stress perfusion cardiac computed tomography (SSPCT). Purpose To determine the diagnostic performance of static SSPCT for identifying hemodynamically significant CAD. Material and Methods This prospective study included 29 patients with suspected or known CAD who underwent static SSPCT, cardiovascular magnetic resonance myocardial perfusion imaging (CMR-MPI), and invasive coronary angiography (ICA). CT was performed as follows: (i) coronary calcium scan; (ii) static SSPCT for both coronary artery (coronary CT angiography [CCTA]) and myocardial perfusion (perfusion CT [PCT]) during adenosine infusion; (iii) late-phase scan. The diagnostic performance of CCTA alone, PCT alone, and SSPCT for the detection of a hemodynamically significant CAD (a perfusion defect in a vascular territory subtended by a coronary vessel with ≥ 50% stenosis) was compared with that of combined ICA/CMR-MPI representing the standard of reference. Results Twenty-three (79%) patients and 47 (54%) vascular territories manifested ischemia-causing coronary stenoses by combined ICA/CMR-MPI. The per-vessel sensitivity, specificity, positive and negative predictive values, and area under the receiver operating characteristic curve (AUC) of the SSPCT were 92%, 88%, 90%, 90%, and 0.90, respectively, compared to those of the combined ICA/CMR-MPI. These values for the CCTA alone were 96%, 63%, 75%, 93%, and 0.79, respectively; and the values for the PCT alone were 94%, 83%, 86%, 92%, and 0.88, respectively. The AUC of SSPCT was significantly ( P = 0.013) higher than that of the CCTA alone. Conclusion Static SSPCT may facilitate detection of hemodynamically significant CAD.

Low-dose dynamic myocardial perfusion CT imaging using a motion adaptive sparsity prior

PURPOSE

Dynamic myocardial perfusion computed tomography (DM-PCT) imaging offers benefits over quantitative assessment of myocardial blood flow (MBF) for diagnosis and risk stratification of coronary artery disease. However, one major drawback of DM-PCT imaging is that a high radiation level is imparted by repeated scanning. To address this issue, in this work, we developed a statistical iterative reconstruction algorithm based on the penalized weighted least-squares (PWLS) scheme by incorporating a motion adaptive sparsity prior (MASP) model to achieve high-quality DM-PCT imaging with low tube current dynamic data acquisition. For simplicity, we refer to the proposed algorithm as "PWLS-MASP''.

METHODS

The MASP models both the spatial and temporal structured sparsity of DM-PCT sequence images with the assumption that the differences between adjacent frames after motion correction are sparse in the gradient image domain. To validate and evaluate the effectiveness of the present PWLS-MASP algorithm thoroughly, a modified XCAT phantom and preclinical porcine DM-PCT dataset were used in the study.

RESULTS

The present PWLS-MASP algorithm can obtain high-quality DM-PCT images in both phantom and porcine cases, and outperforms the existing filtered back-projection algorithm and PWLS-based algorithms with total variation regularization (PWLS-TV) and robust principal component analysis regularization (PWLS-RPCA) in terms of noise reduction, streak artifacts mitigation, and time density curve estimation. Moreover, the PWLS-MASP algorithm can yield more accurate diagnostic hemodynamic parametric maps than the PWLS-TV and PWLS-RPCA algorithms.

CONCLUSIONS

The study indicates that there is a substantial advantage in using the present PWLS-MASP algorithm for low-dose DM-PCT, and potentially in other dynamic tomography areas.

Myocardial Assessment with Cardiac CT: Ischemic Heart Disease and Beyond

PURPOSE OF REVIEW

The aim of this review is to highlight recent advancements, current trends, and the expanding role for cardiac CT (CCT) in the evaluation of ischemic heart disease, nonischemic cardiomyopathies, and some specific congenital myocardial disease states.

RECENT FINDINGS

CCT is a highly versatile imaging modality for the assessment of numerous cardiovascular disease states. Coronary CT angiography (CCTA) is now a well-established first-line imaging modality for the exclusion of significant coronary artery disease (CAD); however, CCTA has modest positive predictive value and specificity for diagnosing obstructive CAD in addition to limited capability to evaluate myocardial tissue characteristics.

SUMMARY

CTP, when combined with CCTA, presents the potential for full functional and anatomic assessment with a single modality. CCT is a useful adjunct in select patients to both TTE and CMR in the evaluation of ventricular volumes and systolic function. Newer applications, such as dynamic CTP and DECT, are promising diagnostic tools offering the possibility of more quantitative assessment of ischemia. The superior spatial resolution and volumetric acquisition of CCT has an important role in the diagnosis of other nonischemic causes of cardiomyopathies.

Additive value of 3T cardiovascular magnetic resonance coronary angiography for detecting coronary artery disease

BACKGROUND

The purpose of the work was to evaluate the incremental diagnostic value of free-breathing, contrast-enhanced, whole-heart, 3 T cardiovascular magnetic resonance coronary angiography (CE-MRCA) to stress/rest myocardial perfusion imaging (MPI) and late gadolinium enhancement (LGE) imaging for detecting coronary artery disease (CAD).

METHODS

Fifty-one patients with suspected CAD underwent a comprehensive cardiovascular magnetic resonance (CMR) examination (CE-MRCA, MPI, and LGE). The additive diagnostic value of MRCA to MPI and LGE was evaluated using invasive x-ray coronary angiography (XA) as the standard for defining functionally significant CAD (≥ 50% stenosis in vessels > 2 mm in diameter).

RESULTS

90.2% (46/51) patients (54.0 ± 11.5 years; 71.7% men) completed CE-MRCA successfully. On per-patient basis, compared to MPI/LGE alone or MPI alone, the addition of MRCA resulted in higher sensitivity (100% vs. 76.5%, p < 0.01), no change in specificity (58.3% vs. 66.7%, p = 0.6), and higher accuracy (89.1% vs 73.9%, p < 0.01) for CAD detection (prevalence = 73.9%). Compared to LGE alone, the addition of CE-MRCA resulted in higher sensitivity (97.1% vs. 41.2%, p < 0.01), inferior specificity (83.3% vs. 91.7%, p = 0.02), and higher diagnostic accuracy (93.5% vs. 54.3%, p < 0.01).

CONCLUSION

The inclusion of successful free-breathing, whole-heart, 3 T CE-MRCA significantly improved the sensitivity and diagnostic accuracy as compared to MPI and LGE alone for CAD detection.

Non-invasive assessment of the haemodynamic significance of coronary stenosis using fusion of cardiac computed tomography and 3D echocardiography

Aims

Abnormal computed tomography coronary angiography (CTCA) often leads to stress testing to determine haemodynamic significance of stenosis. We hypothesized that instead, this could be achieved by fusion imaging of the coronary anatomy with 3D echocardiography (3DE)-derived resting myocardial deformation.

Methods and results

We developed fusion software that creates combined 3D displays of the coronary arteries with colour maps of longitudinal strain and tested it in 28 patients with chest pain, referred for CTCA (256 Philips scanner) who underwent 3DE (Philips iE33) and regadenoson stress CT. To obtain a reference for stenosis significance, coronaries were also fused with colour maps of stress myocardial perfusion. 3D displays were used to detect stress perfusion defect (SPD) and/or resting strain abnormality (RSA) in each territory. CTCA showed 56 normal arteries, stenosis <50% in 17, and >50% in 8 arteries. Of the 81 coronary territories, SPDs were noted in 20 and RSAs in 29. Of the 59 arteries with no stenosis >50% and no SPDs, considered as normal, 12 (20%) had RSAs. Conversely, with stenosis >50% and SPDs (haemodynamically significant), RSAs were considerably more frequent (5/6 = 83%). Overall, resting strain and stress perfusion findings were concordant in 64/81 arteries (79% agreement).

Conclusions

Fusion of CTCA and 3DE-derived data allows direct visualization of each coronary artery and strain in its territory. In this feasibility study, resting strain showed good agreement with stress perfusion, indicating that it may be potentially used to assess haemodynamic impact of coronary stenosis, as an alternative to stress testing that entails additional radiation exposure.

Fusion of Three-Dimensional Echocardiographic Regional Myocardial Strain with Cardiac Computed Tomography for Noninvasive Evaluation of the Hemodynamic Impact of Coronary Stenosis in Patients with Chest Pain

BACKGROUND

Combined evaluation of coronary stenosis and the extent of ischemia is essential in patients with chest pain. Intermediate-grade stenosis on computed tomographic coronary angiography (CTCA) frequently triggers downstream nuclear stress testing. Alternative approaches without stress and/or radiation may have important implications. Myocardial strain measured from echocardiographic images can be used to detect subclinical dysfunction. The authors recently tested the feasibility of fusion of three-dimensional (3D) echocardiography-derived regional resting longitudinal strain with coronary arteries from CTCA to determine the hemodynamic significance of stenosis. The aim of the present study was to validate this approach against accepted reference techniques.

METHODS

Seventy-eight patients with chest pain referred for CTCA who also underwent 3D echocardiography and regadenoson stress computed tomography were prospectively studied. Left ventricular longitudinal strain data (TomTec) were used to generate fused 3D displays and detect resting strain abnormalities (RSAs) in each coronary territory. Computed tomographic coronary angiographic images were interpreted for the presence and severity of stenosis. Fused 3D displays of subendocardial x-ray attenuation were created to detect stress perfusion defects (SPDs). In patients with stenosis >25% in at least one artery, fractional flow reserve was quantified (HeartFlow). RSA as a marker of significant stenosis was validated against two different combined references: stenosis >50% on CTCA and SPDs seen in the same territory (reference standard A) and fractional flow reserve < 0.80 and SPDs in the same territory (reference standard B).

RESULTS

Of the 99 arteries with no stenosis >50% and no SPDs, considered as normal, 19 (19%) had RSAs. Conversely, with stenosis >50% and SPDs, RSAs were considerably more frequent (17 of 24 [71%]). The sensitivity, specificity, and accuracy of RSA were 0.71, 0.81, and 0.79, respectively, against reference standard A and 0.83, 0.81, and 0.82 against reference standard B.

CONCLUSIONS

Fusion of CTCA and 3D echocardiography-derived resting myocardial strain provides combined displays, which may be useful in determination of the hemodynamic or functional impact of coronary abnormalities, without additional ionizing radiation or stress testing.

Myocardial ischemia testing with computed tomography: emerging strategies

Although cardiac computed tomography (CT) has high negative predictive value to exclude obstructive coronary artery disease (CAD), particularly in the low to intermediate risk population, it has low specificity in the diagnosis of ischemia-inducing lesions. This inability to predict hemodynamically significant stenosis hampers the ability of CT to be an effective gatekeeper for invasive angiography and to guide appropriate revascularization. Recent advances in CT technology have resulted in the development of multiple techniques to provide hemodynamic information and detect lesion-specific ischemia, namely CT perfusion (CTP), CT-derived fractional flow reserve (CT-FFR) and coronary transluminal attenuation gradient (TAG). In this article, we provide a perspective on these emerging CT techniques in the evaluation of myocardial ischemia.

Coronary Artery Disease: Analysis of Diagnostic Performance of CT Perfusion and MR Perfusion Imaging in Comparison with Quantitative Coronary Angiography and SPECT-Multicenter Prospective Trial

Purpose To compare the diagnostic performance of stress myocardial computed tomography (CT) perfusion with that of stress myocardial magnetic resonance (MR) perfusion imaging in the detection of coronary artery disease (CAD). Materials and Methods All patients gave written informed consent prior to inclusion in this institutional review board-approved study. This two-center substudy of the prospective Combined Noninvasive Coronary Angiography and Myocardial Perfusion Imaging Using 320-Detector Row Computed Tomography (CORE320) multicenter trial included 92 patients (mean age, 63.1 years ± 8.1 [standard deviation]; 73% male). All patients underwent perfusion CT and perfusion MR imaging with either adenosine or regadenoson stress. The predefined reference standards were combined quantitative coronary angiography (QCA) and single-photon emission CT (SPECT) or QCA alone. Results from coronary CT angiography were not included, and diagnostic performance was evaluated with the Mantel-Haenszel test stratified by disease status. Results The prevalence of CAD was 39% (36 of 92) according to QCA and SPECT and 64% (59 of 92) according to QCA alone. When compared with QCA and SPECT, per-patient diagnostic accuracy of perfusion CT and perfusion MR imaging was 63% (58 of 92) and 75% (69 of 92), respectively (P = .11); sensitivity was 92% (33 of 36) and 83% (30 of 36), respectively (P = .45); and specificity was 45% (25 of 56) and 70% (39 of 56), respectively (P < .01). When compared with QCA alone, diagnostic accuracy of CT perfusion and MR perfusion imaging was 82% (75 of 92) and 74% (68 of 92), respectively (P = .27); sensitivity was 90% (53 of 59) and 69% (41 of 59), respectively (P < .01); and specificity was 67% (22 of 33) and 82% (27 of 33), respectively (P = .27). Conclusion This multicenter study shows that the diagnostic performance of perfusion CT is similar to that of perfusion MR imaging in the detection of CAD. ^© RSNA, 2017 Online supplemental material is available for this article.

Coronary CT angiography in acute chest pain

Coronary computed tomographic angiography has become a reliable diagnostic tool in the evaluation of patients with chest pain. Studies have shown this modality to be accurate and safe when compared with conventional methods of assessing patients with chest pain. We review the recent developments with coronary computed tomographic angiography and devote particular attention toward its application to triage patients in the emergency department.

Diagnostic accuracy of coronary CT angiography combined with dual-energy myocardial perfusion imaging for detection of myocardial infarction

The aim of the present study was to evaluate the diagnostic accuracy of second generation dual-energy computed tomography (DECT) myocardial perfusion imaging for the detection of myocardial infarction (MI) in patients with suspected MI. In total, 56 patients underwent DECT. Among those, 40 patients had MI that was detected by catheter coronary angiography and cardiac troponin I elevation and evolution of acute MI detected by electrocardiogram changes. The diagnostic accuracy, including the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the detection of MI were evaluated, as well as the coronary image quality of coronary artery and radiation dose. The sensitivity, specificity, PPV and NPV for the detection of MI were 95.0, 97.0, 86.4 and 98.9%, respectively. Moreover, the image quality was rated excellent (score 1) in 90.2% (515/571), good (score 2) in 6.5% (37/571), adequate (score 3) in 1.9% (11/571) and non-diagnostic (score 4) in 1.4% (8/571) of the coronary segments. The effective radiation dose was on average 6.1±1.5 mSv (3.1–10.9 mSv). Therefore, combined DE iodine maps and coronary CT angiography using the DECT may provide a high diagnostic accuracy for detecting MI with lower radiation exposure in patients with suspected MI.

Detection of Hemodynamically Significant Coronary Artery Stenosis With CT Enhancement Ratio: A Validation Study in a Porcine Model

OBJECTIVE

Although numerous techniques that are based on CT number analysis have been proposed, the assessment of hemodynamically significant coronary artery stenosis remains a great challenge. The purpose of this study is to validate use of the CT enhancement ratio in the detection of hemodynamically significant coronary artery stenosis in a porcine model.

MATERIALS AND METHODS

Experiments involving eight closed-chest swine were performed. A balloon catheter was placed into the left anterior descending coronary artery to simulate different degrees of luminal stenosis. The myocardial blood flow (MBF) ratio was measured using the colored microsphere technique. The fractional flow reserve was measured using an invasive pressure wire. CT scans were performed during the first-pass phase, while the pigs were undergoing adenosine stress tests. The CT enhancement ratio and the CT attenuation ratio were calculated using data from the CT images obtained.

RESULTS

Results suggested that the CT enhancement ratio had a strong correlation (y = 0.07245 + 0.09963x; r² = 0.898; p < 0.001) with the MBF ratio measured using the microsphere technique, whereas only moderate correlation (y = -1.5508 + 2.2684x; r² = 0.498; p < 0.001) was noted between the CT attenuation ratio and the MBF ratio measured using the microsphere technique. In ROC curve analysis, the AUC values of the CT enhancement ratio and the CT attenuation ratio were 0.927 and 0.829, respectively, with regard to the detection of significant ischemia during adenosine stress tests, as defined by the fractional flow reserve.

CONCLUSION

The CT enhancement ratio provides a reliable prediction of the MBF ratio measured using the microsphere technique, indicating that this metric has good diagnostic performance in the detection of hemodynamically significant coronary artery stenosis. The CT enhancement ratio may have potential for use as an imaging biomarker for the relative quantitative assessment of myocardial perfusion.

Infarct characterization using CT

Myocardial infarction (MI) is a major cause of death and disability worldwide. The incidence is not expected to diminish, despite better prevention, diagnosis and treatment, because of the ageing population in industrialized countries and unhealthy lifestyles in developing countries. Nowadays it is highly requested an imaging tool able to evaluate MI and viability. Technology improvements determined an expansion of clinical indications from coronary plaque evaluation to functional applications (perfusion, ischemia and viability after MI) integrating additional phases and information in the mainstream examination. Cardiac computed tomography (CCT) and cardiac MR (CMR) employ different contrast media, but may characterize MI with overlapping imaging findings due to the similar kinetics and tissue distribution of gadolinium and iodinated contrast media. CCT may detect first-pass perfusion defects, dynamic perfusion after pharmacological stress, and delayed enhancement (DE) of non-viable territories.

Myocardial CT perfusion imaging for ischemia detection

Coronary computed tomography angiography (CCTA) plays an important role in many specific scenarios such as in symptomatic patients with intermediate pretest of coronary artery disease (CAD), as well as in the triage of patients with acute chest pain with TIMI risk ≤2. However, it cannot detect the presence of associated ischemia, which is critical for clinical decision making among patients with moderate to severe stenosis. Although functional information can be obtained with different non-invasive tools, cardiac CT is the unique modality that can perform a comprehensive evaluation of coronary anatomy plus the functional significance of lesions. Myocardial CT perfusion (CTP) can be performed with different approaches such as static and dynamic CTP. In addition, static CTP can be performed using single energy CT (SECT) or dual energy CT (DECT). In this review, we will discuss the technical parameters and the available clinical evidence of static CTP using both SECT and DECT.

Myocardial blood flow quantification for evaluation of coronary artery disease by computed tomography

During the last decade coronary computed tomography angiography (CTA) has become the preeminent non-invasive imaging modality to detect coronary artery disease (CAD) with high accuracy. However, CTA has a limited value in assessing the hemodynamic significance of a given stenosis due to a modest specificity and positive predictive value. In recent years, different CT techniques for detecting myocardial ischemia have emerged, such as CT-derived fractional flow reserve (FFR-CT), transluminal attenuation gradient (TAG), and myocardial CT perfusion (CTP) imaging. Myocardial CTP imaging can be performed with a single static scan during first pass of the contrast agent, with monoenergetic or dual-energy acquisition, or as a dynamic, time-resolved scan during stress by using coronary vasodilator agents (adenosine, dipyridamole, or regadenoson). A number of CTP techniques are available, which can assess myocardial perfusion in both a qualitative, semi-quantitative or quantitative manner. Once used primarily as research tools, these modalities are increasingly being used in routine clinical practice. All these techniques offer the substantial advantage of combining anatomical and functional evaluation of flow-limiting coronary stenosis in the same examination that would be beneficial for clinical decision-making. This review focuses on the state-of the-art and future trends of these evolving imaging modalities in the field of cardiology for the physiologic assessments of CAD.

Low-dose dynamic myocardial perfusion CT image reconstruction using pre-contrast normal-dose CT scan induced structure tensor total variation regularization

Dynamic myocardial perfusion CT (DMP-CT) imaging provides quantitative functional information for diagnosis and risk stratification of coronary artery disease by calculating myocardial perfusion hemodynamic parameter (MPHP) maps. However, the level of radiation delivered by dynamic sequential scan protocol can be potentially high. The purpose of this work is to develop a pre-contrast normal-dose scan induced structure tensor total variation regularization based on the penalized weighted least-squares (PWLS) criteria to improve the image quality of DMP-CT with a low-mAs CT acquisition. For simplicity, the present approach was termed as 'PWLS-ndiSTV'. Specifically, the ndiSTV regularization takes into account the spatial-temporal structure information of DMP-CT data and further exploits the higher order derivatives of the objective images to enhance denoising performance. Subsequently, an effective optimization algorithm based on the split-Bregman approach was adopted to minimize the associative objective function. Evaluations with modified dynamic XCAT phantom and preclinical porcine datasets have demonstrated that the proposed PWLS-ndiSTV approach can achieve promising gains over other existing approaches in terms of noise-induced artifacts mitigation, edge details preservation, and accurate MPHP maps calculation.

Temporal averaging for analysis of four-dimensional whole-heart computed tomography perfusion of the myocardium: proof-of-concept study

To assess the feasibility of four-dimensional (4D) whole-heart computed tomography perfusion (CTP) of the myocardium and the added value of temporal averaging of consecutive 3D datasets from different heartbeats for analysis. We included 30 patients with suspected or known coronary artery disease (CAD) who underwent 320-row coronary CT angiography (CTA) and myocardial CTP. Out of these, 15 patients underwent magnetic resonance myocardial perfusion imaging (MR MPI). All CTP examinations were initiated after 3 min of intravenous infusion of adenosine (140 µg/kg/min) and were performed dynamically covering the entire heart every heart beat over a period of 20 ± 3 heart beats. Temporal averaging for dynamic CTP visualisation was analysed for the combination of two, three, four, six, and eight consecutive 3D datasets. Input time attenuation curves (TAC) were delivered from measurement points in the centre of the left ventricle. In all 30 patients, myocardial 4D CTP was feasible and temporal averaging was successfully implemented for all planned combinations of 3D datasets. Temporal averaging of three consecutive 3D datasets showed best performance in the analysis of all CTP image quality parameters: noise, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), subjective image quality, and diagnostic accuracy with an improvement of SNR and CNR by a factor of 2.2 ± 1.3 and 1.3 ± 0.9. With increasing level of temporal averaging, the input TACs became smoother, but also shorter. Out of the 11 perfusion defects detected with MR MPI, 9 defects were also visible on the 4D CTP images. Whole-heart CTP of the myocardium is feasible and temporal averaging of dynamic datasets improves quantitative image quality parameters and visualization of perfusion defects while further studies are needed to assess its added value for quantification of perfusion parameters.

Myocardial perfusion 320-row multidetector computed tomography-guided treatment strategy for the clinical management of patients with recent acute-onset chest pain: Design of the CArdiac cT in the treatment of acute CHest pain (CATCH)-2 randomized controlled trial

AIMS

Patients admitted with chest pain are a diagnostic challenge because the majority does not have coronary artery disease (CAD). Assessment of CAD with coronary computed tomography angiography (CCTA) is safe, cost-effective, and accurate, albeit with a modest specificity. Stress myocardial computed tomography perfusion (CTP) has been shown to increase the specificity when added to CCTA, without lowering the sensitivity. This article describes the design of a randomized controlled trial, CATCH-2, comparing a clinical diagnostic management strategy of CCTA alone against CCTA in combination with CTP.

METHODS

Patients with acute-onset chest pain older than 50 years and with at least one cardiovascular risk factor for CAD are being prospectively enrolled to this study from 6 different clinical sites since October 2013. A total of 600 patients will be included. Patients are randomized 1:1 to clinical management based on CCTA or on CCTA in combination with CTP, determining the need for further testing with invasive coronary angiography including measurement of the fractional flow reserve in vessels with coronary artery lesions. Patients are scanned with a 320-row multidetector computed tomography scanner. Decisions to revascularize the patients are taken by the invasive cardiologist independently of the study allocation. The primary end point is the frequency of revascularization. Secondary end points of clinical outcome are also recorded.

DISCUSSION

The CATCH-2 will determine whether CCTA in combination with CTP is diagnostically superior to CCTA alone in the management of patients with acute-onset chest pain.

Update on Computed Tomography Myocardial Perfusion Imaging

PURPOSE OF REVIEW

Computed tomography (CT) coronary angiography is a well-validated non-invasive technique for accurate and expedient diagnosis of coronary artery disease (CAD). However, a limitation of coronary CT angiography (CCTA) is its limited capability to identify physiologically significant stenoses, which may eventuate the need for further functional testing. Stress CT myocardial perfusion imaging (CT-MPI) is an emerging technique that has the ability to identify flow-limiting stenoses.

RECENT FINDINGS

The combination of CCTA coronary and CT-MPI has transformed the modality from a tool to assess anatomy and morphology to a modality capable of simultaneous assessment of coronary stenoses and their physiologic significance. A growing number of studies have demonstrated the feasibility and diagnostic accuracy of CT-MPI in comparison to a number of reference standard modalities for CAD diagnosis, including single-photon emission CT, cardiovascular magnetic resonance imaging, and invasive coronary angiography with and without fractional flow-reserve testing.

SUMMARY

While there is still a need for consensus regarding acquisition techniques as well as analysis and interpretation of CT-MPI, with further validation, it is likely to become a powerful adjunctive tool to CCTA in the management of patients with suspected coronary disease.

Computed tomography myocardial perfusion vs 15O-water positron emission tomography and fractional flow reserve

Objectives

Computed tomography (CT) can perform comprehensive cardiac imaging. We compared CT coronary angiography (CTCA) and CT myocardial perfusion (CTP) with ¹⁵O-water positron emission tomography (PET) and invasive coronary angiography (ICA) with fractional flow reserve (FFR).

Methods

51 patients (63 (61–65) years, 80 % male) with known/suspected coronary artery disease (CAD) underwent 320-multidetector CTCA followed by “snapshot” adenosine stress CTP. Of these 22 underwent PET and 47 ICA/FFR. Obstructive CAD was defined as CTCA stenosis >50 % and CTP hypoperfusion, ICA stenosis >70 % or FFR <0.80.

Results

PET hyperaemic myocardial blood flow (MBF) was lower in obstructive than non-obstructive territories defined by ICA/FFR (1.76 (1.32–2.20) vs 3.11 (2.44–3.79) mL/(g/min), P < 0.001) and CTCA/CTP (1.76 (1.32–2.20) vs 3.12 (2.44–3.79) mL/(g/min), P < 0.001). Baseline and hyperaemic CT attenuation density was lower in obstructive than non-obstructive territories (73 (71–76) vs 86 (84–88) HU, P < 0.001 and 101 (96–106) vs 111 (107–114) HU, P 0.001). PET hyperaemic MBF corrected for rate pressure product correlated with CT attenuation density (r = 0.579, P < 0.001). There was excellent per-patient sensitivity (96 %), specificity (85 %), negative predictive value (90 %) and positive predictive value (94 %) for CTCA/CTP vs ICA/FFR.

Conclusion

CT myocardial attenuation density correlates with ¹⁵O-water PET MBF. CTCA and CTP can accurately identify obstructive CAD.

Key Points

•CT myocardial perfusion can aid the assessment of suspected coronary artery disease.

• CT attenuation density from “snapshot” imaging is a marker of myocardial perfusion.

• CT myocardial attenuation density correlates with¹⁵O-water PET myocardial blood flow.

• CT attenuation density is lower in obstructive territories defined by invasive angiography.

• Diagnostic accuracy of CTCA+CTP is comparable to invasive angiography + fractional flow reserve.

Electronic supplementary material

The online version of this article (doi:10.1007/s00330-016-4404-5) contains supplementary material, which is available to authorized users.

Sudden cardiac death from structural heart diseases in adults: imaging findings with cardiovascular computed tomography and magnetic resonance

Sudden cardiac death (SCD) is defined as the unexpected natural death from a cardiac cause within an hour of the onset of symptoms in the absence of any other cause. Although such a rapid course of death is mainly attributed to a cardiac arrhythmia, identification of structural heart disease by cardiovascular computed tomography (CCT) and cardiovascular magnetic resonance (CMR) imaging is important to predict the long-term risk of SCD. In adults, SCD most commonly results from coronary artery diseases, coronary artery anomalies, inherited cardiomyopathies, valvular heart diseases, myocarditis, and aortic dissection with coronary artery involvement or acute aortic regurgitation. This review describes the CCT and CMR findings of structural heart diseases related to SCD, which are essential for radiologists to diagnose or predict.