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13 Cardiovascular CT for Assessment of Pericardial/Myocardial
Disease Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Muhammad Aamir Latif and Khurram Nasir
14 Computed Tomography Evaluation in Valvular Heart Disease . . . . . . . . . . . . . . 241
Nada Shaban , Javier Sanz , Leticia Fernández Friera ,
and Mario Jorge García
15 Transcatheter Aortic Valve Implantation (TAVI) . . . . . . . . . . . . . . . . . . . . . . . . . 255
Chesnal Dey Arepalli , Christopher Naoum , Philipp Blanke ,
and Jonathon A. Leipsic
16 Assessment of Cardiac and Thoracic Masses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Jabi E. Shriki , Patrick M. Colletti , and Suresh Maximin
Part IV CT Vascular Angiography
17 CT Angiography of the Peripheral Arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
Jabi E. Shriki, Leonardo C. Clavijo, and Gale L. Tang
18 Aortic, Renal, Mesenteric and Carotid CT Angiography . . . . . . . . . . . . . . . . . . . 319
Anas Alani and Matthew J. Budoff
19 Assessment of Pulmonary Vascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
Bradley S. Messenger and Ronald J. Oudiz
Part V Multidisciplinary Topics
20 Value Based Imaging for Coronary Artery Disease: Implications
for Nuclear Cardiology and Cardiac CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
Daniel S. Berman , Alan Rozanski , Piotr Slomka , Rine Nakanishi , Damini Dey ,
John D. Friedman , Sean W. Hayes , Louise E. J. Thomson , Reza Arsanjani ,
Rory Hachamovitch , James K. Min , Leslee J. Shaw , and Guido Germano
21 Coronary Computed Tomographic Angiography for Detection
of Coronary Artery Disease: Analysis of Large-Scale Multicenter
Trials and Registries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
Leslee J. Shaw
22 Cardiothoracic Surgery Applications: Virtual CT Imaging
Approaches to Procedural Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
Jerold S. Shinbane, Craig J. Baker, Mark J. Cunningham,
and Vaughn A. Starnes
23 Computed Tomographic Angiography in the Assessment of Congenital
Heart Disease and Coronary Artery Anomalies . . . . . . . . . . . . . . . . . . . . . . . . . . 429
Priya Pillutla and Stephen C. Cook
24 CCTA Cardiac Electrophysiology Applications: Substrate Identification,
Virtual Procedural Planning, and Procedural Facilitation . . . . . . . . . . . . . . . . . . 455
Jerold S. Shinbane , Leslie A. Saxon , Rahul N. Doshi , Philip M. Chang ,
and Matthew J. Budoff
25 Cardiovascular CT: Interventional Cardiology Applications . . . . . . . . . . . . . . . . 487
Jeffrey M. Schussler
Contents
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26 Cardiovascular Magnetic Resonance Imaging: Overview of Clinical
Applications in the Context of Cardiovascular CT . . . . . . . . . . . . . . . . . . . . . . . . 507
Jerold S. Shinbane, Jabi E. Shriki, Antreas Hindoyan, and Patrick M. Colletti
27 Cardiovascular CT in the Emergency Department . . . . . . . . . . . . . . . . . . . . . . . . 549
Asim Rizvi and James K. Min
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561
Contents
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Stephan Achenbach , MD University of Erlangen , Erlangen , Germany
Anas Alani , MD Department of Medicine , University of Florida – Gainesville , Gainsville ,
FL , USA
Los Angeles Biomedical Research Institute at Harbor-UCLA , Torrance , CA , USA
Chesnal Dey Arepalli , MBBS, DNB Department of Radiology , St. Paul’s Hospital ,
Vancouver , BC , Canada
Reza Arsanjani , MD Departments of Imaging and Medicine , Cedars-Sinai Medical Center
and the Cedars-Sinai Heart Institute , Los Angeles , CA , USA
Craig J. Baker , MD, FACS Department of Surgery , Keck Hospital of the University of
Southern California , Los Angeles , CA , USA
Daniel S. Berman , MD Departments of Imaging and Medicine , Cedars-Sinai Medical Center
and the Cedars-Sinai Heart Institute , Los Angeles , CA , USA
Philipp Blanke , MD Department of Medicine , St. Paul’s Hospital , Vancouver , BC , Canada
Matthew J. Budoff , MD David Geffen School of Medicine at UCLA , Los Angeles Biomedical
Research Institute , Torrance , CA , USA
Phillip M. Chang , MD Department of Medicine , Keck Medical Center of USC/Keck School
of Medicine at USC , Los Angeles , CA , USA
Leonardo C. Clavijo , MD, PhD, FACC, FSCAI, FSVM Department of Medicine ,
Division of Cardiovascular Medicine, Department of Clinical Medicine, University of
Southern California , Los Angeles , CA , USA
Patrick M. Colletti , MD Department of Radiology , University of Southern California ,
Los Angeles , CA , USA
Stephen C. Cook , MD, FACC Adult Congenital Heart Disease Center , Heart Institute,
Children’s Hospital of Pittsburgh of UPMC , Pittsburgh , PA , USA
Mark J. Cunningham , MD Department of Surgery , Keck Hospital of the University of
Southern California , Los Angeles , CA , USA
Damini Dey , PhD Departments of Imaging and Medicine , Cedars-Sinai Medical Center and
the Cedars-Sinai Heart Institute , Los Angeles , CA , USA
Rahul N. Doshi , MD, FACC, FHRS Department of Medicine , Keck Medical Center of USC ,
Los Angeles , CA , USA
Joachim Eckert , MD Department of Cardiology , Cardioangiologisches Centrum Bethanien ,
Frankfurt , Hessen , Germany
Contributors
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xiv
John D. Friedman , MD Departments of Imaging and Medicine , Cedars-Sinai Medical Center
and the Cedars-Sinai Heart Institute , Los Angeles , CA , USA
Leticia Fernández Friera , MD Department of Medicine , Division of Cardiology , Mount
Sinai Medical Center , New York , NY , USA
Centro Nacional de Investigaciones Cardiovasculares , Madrid , Spain
Mario Jorge Garcia , MD, FACC, FACP Division of Cardiology , Montefi ore Medical Center ,
Bronx , NY , USA
Guido Germano , PhD Departments of Imaging and Medicine , Cedars-Sinai Medical Center
and the Cedars-Sinai Heart Institute , Los Angeles , CA , USA
Ilan Gottlieb , MD, MSc, PhD Casa de Saude Sao Jose , Rio de Janeiro , RJ , Brazil
Swaminatha V. Gurudevan , MD, FACC Department of Medicine , Healthcare Partners
Medical Group , Pasadena , CA , USA
Rory Hachamovitch , MD Department of Nuclear Medicine , Cleveland Clinic, Heart and
Vascular Institute , Cleveland , OH , USA
Sean W. Hayes , MD Departments of Imaging and Medicine , Cedars-Sinai Medical Center
and the Cedars-Sinai Heart Institute , Los Angeles , CA , USA
Harvey S. Hecht , MD, FACC, FSSCT Department of Medicine , Icahn School of Medicine
at Mount Sinai , New York , NY , USA
Mount Sinai Medical Center , New York , NY , USA
Antreas Hindoyan , MD Division of Cardiovascular Medicine, Department of Internal
Medicine , Keck School of Medicine of the University of Southern California , Los Angeles ,
CA , USA
Muhammad Aamir Latif , MD Department of Medicine , Center for Healthcare Advancement
and Outcomes , Baptist Health South Florida , Miami , FL , USA
Kai H. Lee , PhD Associate Professor of Clinical Radiology, Department of Radiology, Keck
School of Medicine , University of Southern California , Los Angeles , CA , USA
Jonathon A. Leipsic , MD, FRCPC, FSCCT Department of Radiology , St. Paul’s Hospital ,
Vancouver , BC , Canada
João A. C. Lima , MD Division of Cardiology , Johns Hopkins Hospital , Baltimore , MD , USA
Songshou Mao , MD Department of Medicine , Los Angeles Biomedical Research Institute ,
Los Angeles , CA , USA
Suresh Maximin , MD Department of Radiology, University of Washington ,
Seattle , WA , USA
Bradley S. Messenger , MD Division of Cardiology, Department of Medicine , Harbor-UCLA
Medical Center , Torrance , CA , USA
James K. Min , MD, FACC Department of Radiology , Dalio Institute of Cardiovascular
Imaging, Weill Cornell Medical College and the NewYork Presbyterian Hospital , New York ,
NY , USA
Rine Nakanishi , MD, PhD Department of Medicine , Cardiac CT, Los Angeles Biomedical
Research Institute at Harbor-UCLA , Torrance , CA , USA
Christopher Naoum , MBBS, FRACP Department of Radiology , St. Paul’s Hospital ,
Vancouver , BC , Canada
Contributors
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Khurram Nasir , MD, MPH Department of Medicine, Center for Healthcare Advancement
and Outcomes , Baptist Health South Florida , Miami Beach , FL , USA
Ronald J. Oudiz , MD Department of Medicine, Los Angeles Biomedical Research
Institute , The David Geffen School of Medicine at UCLA, Harbor-UCLA Medical Center ,
Torrance , CA , USA
Priya Pillutla , MD Adult Congenital Heart Disease Program , Harbor-UCLA Medical Center ,
Torrance , CA , USA
Paolo Raggi , MD Department of Medicine , Mazankowski Alberta Heart Institute, University
of Alberta , Edmonton , AB , Canada
Asim Rizvi , MD Department of Radiology , Dalio Institute of Cardiovascular Imaging, Weill
Cornell Medical College and the NewYork Presbyterian Hospital , New York , NY , USA
Alan Rozanski , MD Division of Cardiology , Mt. Sinai Saint Luke’s and Roosevelt Hospitals ,
New York , NY , USA
John A. Rumberger , PhD, MD Cardiac Imaging , The Princeton Longevity Center , Princeton ,
NJ , USA
Javier Sanz , MD Department of Medicine, Division of Cardiology , Mount Sinai Medical
Center , New York , NY , USA
Leslie A. Saxon , MD Department of Medicine , USC Center for Body Computing, Keck
Medical Center of USC , Los Angeles , CA , USA
Axel Schmermund , MD Department of Cardiology , Cardioangiologisches Centrum
Bethanien , Frankfurt , Hessen , Germany
Marco J. M. Schmidt , MD Department of Cardiology , Cardioangiologisches Centrum
Bethanien , Frankfurt , Hessen , Germany
Jeffrey M. Schussler , MD, FACC, FSCAI, FSCCT, FACP Division of Cardiology,
Department of Internal Medicine, Baylor University Medical Center, Dallas, TX/Jack and Jane
Hamilton Heart and Vascular Hospital , Dallas , TX , USA
Division of Cardiology, Department of Medicine, Texas A&M College of Medicine ,
Dallas , TX , USA
Nada Shaban , MD Department of Medicine, Division of Cardiology , North Shore University
Hospital , Manhasset , NY , USA
Ravi K. Sharma , MD Division of Cardiology, Johns Hopkins Hospital , Baltimore , MD , USA
Leslee Shaw , PhD Department of Medicine , Emory Clinical Cardiovascular Research
Institute, Emory University School of Medicine , Atlanta , GA , USA
Jerold S. Shinbane , MD, FACC, FHRS, FSCCT Division of Cardiovascular Medicine,
Department of Internal Medicine , Keck School of Medicine of the University of Southern
California , Los Angeles , CA , USA
Jabi E. Shriki , MD Department of Radiology , Puget VA Health System, University of
Washington , Seattle , WA , USA
Piotr Slomka , PhD Departments of Imaging and Medicine , Cedars-Sinai Medical Center and
the Cedars-Sinai Heart Institute , Los Angeles , CA , USA
Vaughn A. Starnes , MD H. Russell Smith Foundation , Cardiovascular Thoracic Institute,
Keck Hospital of the University of Southern California , Los Angeles , CA , USA
Contributors
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xvi
Gale L. Tang , MD Department of Surgery , University of Washington , Seattle , WA , USA
Louise E. J. Thomson , MBChB Departments of Imaging and Medicine , Cedars-Sinai
Medical Center and the Cedars-Sinai Heart Institute , Los Angeles , CA , USA
Thomas Voigtländer , MD Department of Cardiology , Cardioangiologisches Centrum
Bethanien , Frankfurt , Hessen , Germany
Wm. Guy Weigold , MD, FACC, FSCCT Department of Medicine , Department of Medicine
(Cardiology), Cardiac CT , MedStar Washington Hospital Center , Washington , DC , USA
Cardiac CT Core Lab, MedStar Health Research Institute , Washington , DC , USA
MedStar Cardiovascular Research Network , Washington , DC , USA
Contributors
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Part I
Overview
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3
© Springer International Publishing 2016
M.J. Budoff, J.S. Shinbane (eds.), Cardiac CT Imaging: Diagnosis of Cardiovascular Disease,
DOI 10.1007/978-3-319-28219-0_1
Computed Tomography
Matthew J. Budoff
Abstract
Cardiac CT scanners are rapidly improving, each major vendor has introduced a state of the
art scanner every 2–3 years. The basic applications, terminology and acquisition has not
changed dramatically, however, improvements in hardware and software continue to reduce
radiation exposure, scan times, artifacts and improve image quality. This chapter outlines
the basic CT terminology, functions and background behind the current state of CT scan-
ners for cardiac applications. It reviews spatial, temporal and contrast resolution limits of
the CT scanners. An overview of common terms, radiation exposure and protocols are
included. This acts as an introductory chapter to be expanded by subsequent chapters that
will each go into more details on specifi c topics. Comparison to magnetic resonance for
image quality and functionality, and dose comparisons to mammography, nuclear and
fl uoroscopy are included.
Keywords
Cardiac CT • Angiography • MDCT • MRI • Coronary calcium • Protocols • Radiation •
Spatial resolution • Temporal resolution
Overview of X-ray Computed Tomography
The development of computed tomography (CT), resulting
in widespread clinical use of CT scanning by the early 1980s,
was a major breakthrough in clinical diagnosis across
multiple fi elds. The primary advantage of CT was the ability
to obtain thin cross-sectional axial images, with improved
spatial resolution over ultrasound, nuclear medicine, and
magnetic resonance imaging. This imaging avoided superposition of three-dimensional (3-D) structures onto a planar
2-D representation, as is the problem with conventional
projection X-ray (fl uoroscopy). CT images, which are
inherently digital and thus quite robust, are amenable to 3-D
computer reconstruction, allowing for ultimately nearly an
infi nite number of projections. From a cardiac perspective,
the increased spatial resolution is the reason for its increase
in sensitivity for atherosclerosis, plaque detection and
coronary artery disease (CAD). With CT, smaller objects can
be seen with better image quality. Localization of structures
(in any plane) is more accurate and easier with tomography
than with projection imaging like fl uoroscopy. The exceptional contrast resolution of CT (ability to differentiate fat,
air, tissue and water), allows visualization of more than the
lumen or stent, but rather the plaque, artery wall and other
cardiac and non-cardiac structures simultaneously.
The basic principle of CT is that a fan-shaped, thin X-ray
beam passes through the body at many angles to allow for
cross-sectional imaging. The corresponding X-ray transmission measurements are collected by a detector array.
Information entering the detector array and X-ray beam
itself is collimated to produce thin sections while avoiding
unnecessary photon scatter (to keep radiation exposure and
M. J. Budoff , MD
David Geffen School of Medicine at UCLA ,
Los Angeles Biomedical Research Institute ,
Torrance , CA , USA
e-mail: mbudoff@labiomed.org
1
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4
image noise to a minimum). The x-ray tub and detector
array rotate around the patient separated by 180°, allowing
continuous acquisition of data. The data recorded by the
detectors are digitized into picture elements (pixels) with
known dimensions. The gray-scale information contained
in each individual pixel is reconstructed according to the
attenuation of the X-ray beam along its path using a standardized technique termed “fi ltered back projection.” Grayscale values for pixels within the reconstructed tomogram
are defi ned with reference to the value for water and are
called “Hounsfi eld units” (HU; for the 1979 Nobel Prize
winner, Sir Godfrey N. Hounsfi eld), or simply “CT numbers.” These CT numbers are the attenuation or brightness
of the individual pixel (smallest defi nable unit on CT) of
data. A three dimensional pixel is called a voxel. Typical
pixel values for studies commonly seen on cardiac CT are
listed in Table 1.1 .
Dr Hounsfi eld is credited with the invention of the CT
scanner in late 1960s. Since CT uses X-ray absorption to create images, the differences in the image brightness at any
point will depend on physical density and the presence of
atoms with a high difference in anatomic number like calcium, and soft tissue and water. The absorption of the X-ray
beam by different atoms will cause differences in CT brightness on the resulting image (contrast resolution). Blood and
soft tissue (in the absence of vascular contrast enhancement)
have similar density and consist of similar proportions of the
same atoms (hydrogen, oxygen, carbon). Bone has an abundance of calcium and is thus brighter on CT. Fat has an abundance of hydrogen. Lung contains air which is of extremely
low physical density and appears black on CT (HU −1000).
The higher the density, the brighter the structure on
CT. Calcium is bright white, air is black, and muscle or
blood is gray. There are over 5000 shades of this gray scale
represented on CT, centered around zero (water- gray).
Computed tomography, therefore, can distinguish blood
from air, fat and bone but not readily from muscle or other
soft tissue. The densities of blood, myocardium, thrombus,
and fi brous tissues are so similar in their CT number, that
non-enhanced CT cannot distinguish these structures. Thus,
the ventricles and other cardiac chambers can be seen on
non-enhanced CT, but delineating the wall from the blood
pool is not possible (Fig. 1.1 ). Investigators have validated
the measurement of “LV size” with cardiac CT, which is the
sum of both left ventricle (LV) mass and volume [ 1 ]. Due to
the thin wall which does not contribute signifi cantly to the
total measured volume, the left and right atrial volumes can
be accurately measured on non-contrast CT [ 2 ].
Because contrast resolution uses attenuation or density to
visualize structures in gray scale, limitations of contrast resolution exist even on contrast enhanced studies. These
include differentiating the cardiac vessels from cardiac cavities with same density (such as when the arteries run become
intra-myocardial), and differentiating non-calcifi ed plaque
from surrounding low density structures, including thrombus. Even with good contrast enhancement, differentiating
different types of plaque (lipid-laden and fi brous) can sometimes be challenging, although it is always easy to differentiate the bright white plaques (calcifi ed) from non-calcifi c
plaques.
Table 1.1 Typical Hounsfi eld unit values
Air ~ −1000 HU
Fat −100 to −40
Water – zero
Non-enhanced myocardium and blood – 40–60
Contrast enhanced myocardium 80–140
Calcium >130 (to about 1000)
Enhanced blood pools (lumen, aorta, LV) 300–500
Metal >1000
Fig. 1.1 A non-contrast CT scan of the heart. Quite a bit of information
can be garnered without contrast. The pericardium is visible as a thin
line just below the R and L. The coronary arteries can be seen, and
diameters and calcifi cations are present. The right coronary artery is
seen near the R, the left anterior at the L, and the circumfl ex at the
C. The four chambers of the heart are also seen, and relative sizes can
be measured from this non-contrast study. The interatrial septum is
clearly seen ( red arrow ). The ascending aorta is also present on this
image and can be evaluated. Ao aorta, L left anterior descending artery,
LA left atrium, LV left ventricle, RA right atrium, RV right ventricle
M.J. Budoff
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