Chapters Transcript Video Advances in Cardiac CT Dr. Sarah Joyner shares an update for current uses for cardiac CT and future advances in the imaging world. So I'm gonna be talking about CT I have no financial disclosures to make. So initially, we're gonna talk about some uses for CT. I know some people here um probably have a fair amount of experience of CT and then others. This may be um newer information. So we're gonna go over some current uses. I'm gonna talk about some niche indications for some additional interesting findings and then some future advances for cardiac CT. It's gonna be in a case format. I've presented, I've put questions but you know, I'm happy to have your answer but you do not have to. We'll just continue. Um case number one, you have a 48 year-old man history of hypertension and a family history of C ad that was referred for lipid management. His physical exam was unremarkable and you did a fasting lipid panel and it had mildly elevated lipid results. You recommended lifestyle modifications and you discussed considering doing a lipid lowering medication, but he was pretty hesitant after you did a course of lifestyle modifications, you decided to repeat the lipid panel and again, they were unfortunately elevated a little bit of reduction but not significantly. So in the office we're thinking about, are there any other imaging tests that may be helpful? So we talked to this patient about considering doing something called a calcium score or AC T heart noncontrast study, which I know many of you are familiar with, with this study. There's no IV needed. It's noncontrast, there is radiation expo exposure and it's unfortunately not a cover by insurance. Just as a side note, when we're talking about CT within the majority of our reports, locally, they are read by radiology and cardiology. So when you're seeing the report, there will be two portions of the report. One is radiology's report of the any incidental noncardiac findings and then cardiology's report of the cardiovascular findings and they'll both be embedded in the same report. So, unfortunately, this patient does have severe L ad calcification. I'm gonna um I'm gonna use a pointer occasionally on this slide. Can you all see from over there? Um So this the white area similar to the bone is calcium. So severe amount of L ad calcification. So this was informative. We brought him back to the office, not how we read, but you can pull it up on packs and show the patient and both for lifestyle modification, encouragement and also encouragement in terms of um consideration for medication and also for helping to make your decision whether or not to start medication, this can be helpful. So what is significant? Calcium zero? You would love for your patient. No corne art calcium minimal is considered 1 to 10, 11 to 100 is mild amount of calcification. 101 to 3 99 moderate and then greater than or equal to 400 severe. Unfortunately, we've seen 1000 5000 over than that. So it can be very high in some patients. Case number 2 46 year-old woman history of hyperlipidemia with atypical chest pain. she presents for a consult in the office. She had an abnormal stress echo evidence of some mild wal motion abnormalities and they were suggestive of ischemia. Her physical exam was unremarkable and she was sort of feeling better and you wanted to do further evaluation. But you were considering what were options to do further evaluation in this patient. So we decided to talk to the patient about considering getting a cardiac CT A. Now this study is referred by many names. You all have heard they're all sort of the same cardiac CT, a coronary ct, a heart CT, heart CT A. But the same thing, this is a non-invasive test. You do need an IV. You are gonna give contrasts with this study. They do have radiation and with the iodinated contrast, you're going to assess the renal function and see if they have an iodine contrast allergy. So the prep for it, it is a little different for a couple of reasons than other cat scans. So I describe it to patients, you know, we're now imaging a moving structure. So some things are very important compared with other cat scans. You want the least um motion as possible to prevent them more blurring. But in terms of um the prep for it, you're gonna have no caffeine, we have sort of set protocols and I'm happy to discuss anybody offline the exact hour amount but no caffeine prior to the exam, they're gonna discontinue Metformin and similar to other item um studies. They're going to be MP O prior to the study, you are going to put in an IV. You're gonna give them heart rate, lowering medications and then you're gonna talk to them about a breath hold and you're going to practice the breath hold before they go on the scanner table. No Viagra Cialis Levitra prior to the exam because we do give nitroglycerine when the patient is on the tape on the table prior to the scan to help dilate the vessels. So this patient underwent a critic ct A Now I'm gonna show this sort of some of the best of the Yes, this is a great image quality. I would like to say they all are and for various um patient and other technological reasons, they're not always. So just as a caveat, but this is um this is a normal study. This is the patient's aorta, this is the right coronary artery, you'll see no Luminal, no abnormalities. And then this is the left coronary system, left Maine with the branches. And so this was a normal coronary study for this patient. We didn't have to go on for further testing. Case number 3, 55 year old man, history of hypertension hyperlipidemia diabetes. He came in with chest pain and he had an abnormal nuclear stress test and he was referred for evaluation. And this patient, we proceeded with a heart catheterization and he was found to have mild coronary artery disease and it was an unclear course of his left main coronary artery. And so we're thinking about what tests could be helpful to evaluate further the course of the left main coronary artery. So cardiac CT has a very good um usefulness in the situation. In particular to assess coronary artery anomalies. Coronary artery anomalies are congenital condition. There's an abnormal origin or course of any of the main epoc cardio corne arteries. There's lots of variations to what um constitutes a cor artery anomalies. This isn't going to be um complete, but I'm gonna give one example. It unfortunately can be a cause of sudden cardiac death, but it can also be an incidental finding during a diagnostic work up for ischemic heart disease. So in this patient, it did turn out thankfully to just be an incidental finding this patient, the two images on the sides go together. And then I I pulled up this illustration that um is a little bit variation in the other case. But in this case, they have a benign um coronary artery anomaly. So this is the aorta right in the center. This is your right corne cusp. So the right corny artery is coming off as usual and then the left corne artery instead of coming off the left cusp, and this is the inner atrial septum. So this is your non corne cusp. It's coming off your non corne cusp, but they're having a benign course, it's going retro aortic a posterior course. And then in this example, um you can see it's kind of coming along posteriorly. This is just a little bit variation, but I thought it was easier to see in terms of the illustration. This is a patient that the left coronary artery was coming off the right coronary artery and it had a separate ostium. So it can be very helpful and complementary. So, you know, I think all of the imaging modalities in cardiology are very useful and they can complement each other. So case for 58 year old woman history of breast cancer and she is um actively receiving treatment with chemotherapy and radiation and she came in with dismal exertion. You didn't echo cardiogram that her ef is normal thankfully and she has no significant Vaulter disease. So you proceeded with the nuclear stress test and her stress test came back with a small size, moderate severity anti perfusion defect. And you were trying to weigh what were, you know, the best way to proceed with this woman. You looked at her labs, her hemoglobin was low at eight. Her platelets were low at 100. And so you talked to her about options. And for this patient, you decided not to go straight for a heart catheterization and to start with a cardiac CT. And you're glad in this patient that you did proceed with further imaging. This is the CT and she does have a high L ad, high grade L ad stenosis. This is her cat images and thankfully, she underwent successful intervention and did well. Case number 5 67 year old man, history of ce D, he had a prior cabbage. It was remote about 18 years ago. You have no operative report and he came in with unstable angina symptoms. You proceeded with the cat and you noted that his Lima is led S Patton, you saw that one of the SVGS was occluded and you weren't really sure from what he's describing and what you're seeing whether or not you saw all and visualize all the bypass graphs. And so what test could be helpful? Well, in this situation, not always needed, but sometimes can be helpful when you cannot view or cannot see well, all the bypass graphs. So this patient unfortunately had two vein graphs that were included and this is the aorta with the two stumps visualized and unfortunately, both were included. This patient um uh is somebody that we were considering for repeat redo cabbage evaluation. These are not that patient's image, but I wanted to highlight another usefulness for CT. All patients undergoing redo cabbage are not having but they can be helpful to see how, how close are the bypass graphs to the sternum. So this is a patient that the bypass graph. This is a Lima is very close to the sternum. So this can be very helpful for the surgeons to know going in. I just wanted to highlight one other um cabbage evaluation usefulness. A different patient. We're we're seeing a high grade vein graft to the marginal stenosis. And then this is sort of seeing in longer view. A Lima to the L AD. Um Again, I'm showing the best images. They're not always this wonderful for bypass graph patients, um bypass graphs can have artifact from metal, from clips. They can have most of the patients have native a fair amount of calcification. So for patients with prior cabbage or prior stents, CT is generally not the first line um test for ischemic evaluation. Case number 6, 85 year old woman history, hypertension hyperlipidemia COPD. She has longstanding cardia murmur and she came in with this meal exertion. Her echo shows a normal ef and you find severe aortic valve stenosis. So she underwent cath and no high grade coronary artery disease. But again, you saw the severe a stenosis and she underwent aortic balloon valvula plasty. You consulted CT surgery, but you were already concerned about her cardiac surgery risk. But you were considering at the time, is she a good candidate for Tar versus surgical A VR? And so in this patient, it was determined that she had a high operative risk and she was also not interested in open heart surgery for a VR. And so we began the process and she was undergoing evaluation for TAR. So she proceeded to have a gated chest and abdomen, pelvis ct A and this can be very useful and it's needed for preplan for tab or patients. So you're going to both assess the aorta aortic valve and the iliofemoral arteries. So this is not this patient, this is more an example, but I wanted to be able to illustrate what kind of information you're getting, most of the patients undergoing, have a evaluation are gonna have a, a great amount of calcium. It can make the measurements a little bit more um difficult to display. But on this patient, you're getting diameters, you're getting area perimeter and other useful information that will go back to doctor Tarea and others um to proceed. So this is determining the aortic aulus dimensions. You're also assessing the corne otium height and the aortic valve length that can affect both the sizing and also potential risk and whether or not they're a candidate. And then it also you're gonna look at the iliofemoral arteries. So this is two different patients, but you can see in terms of the approach, this patient here, you know, iliofemoral system looks pretty good and this patient here, very severe calcification and this is images that are seen. Um So again, it can be very useful. Case number 7, 68 year old man history of gird diabetes, chronic kidney disease, hypertension, presented with palpitations and he was found to have new onset atrial fibrillation. You plan to do a te guided cardioversion and you perform the te but it was equivocal for left atrial appendage, Sambas most of the time as you all know, we can generally determine, but in this case, it was equivocal. So what test could be helpful for further evaluation? So in this patient, you decided to proceed with the cardiac CT A and it did confirm evidence of the left atrial appendage thrombus. This is the left atrial appendage here. And then this is a delayed image cat scan image and it confirmed the thrombus there. So we definitely did not proceed with cardioversion. In this patient case number 8 70 nine-year-old man, permanent atrial fibrillation on eloquent and he had balance issues. He was having frequent falls and he was referred for evaluation for left atrial appendage closure device implantation procedure. He underwent the procedure and did well and is now status postle atrial appendage elision procedure. And so could or any postprocedure imaging be helpful to evaluate um the device placement. And so generally after watchmen or other left atrial appendage device placement procedures. A cardiac CT A is performed to confirm adequate placement. So this is good placement in this patient. This is the left atrial appendage with the error left atrial appendage. This is the left atrium. So left atrial appendage. This is the device in place. You can see it in cross section and then it's over on this volume 3d volume, render 3d image, but you can see good placement with no contrast or pacification in the appendage. In contrast to this, this is what you do not want to see and this is not local cases, but these are um so this is a patient that had a device placement but outside the device on the left atrial side has thrombus there. So concerning would want continuation of anticoagulation. This is another patient with a per device leak that it's not sealed well. And then this is incomplete um left atrial appendage closure case number 9, 44 year old man history of atrial fibrillation status. Post cardioversion presents with palpitations and he's back in atrial fibrillation. So the electrophysiology sees him and their planning in atrial fibrillation ablation. Can any testing be helpful for planning a procedure on this patient which is uh they're undergoing a pulmonary vein isolation procedure. The atrial fibrillation ablation, assessing their pulmonary veins prior to is very helpful in this patient. They have normal pulmonary veins which is two right pulmonary veins and two left pulmonary veins. And then also with the CT, we're assessing the left atrial appendage, which in this example, is free of thrombus. But there's a great variation in pulmonary vein anatomy. We um could have multiple slides of the variation. And I've appreciated with CT over the year, how much variation there is. But this is just a couple of examples. In this example, they have a right middle pulmonary vein. This example, there's a left common pulmonary vein and then this is two different variants of left common pulmonary veins. Ones that's short and one that's longer. So again, it can be very helpful for preprocedure planning. OK. Thank you all. Published October 17, 2023 Created by Related Presenters Sarah Joyner, M.D. Sentara Cardiology Specialists View full profile
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