Improved evaluation of calcified segments on coronary CT angiography: a feasibility study of coronary calcium subtraction

We explore the feasibility of coronary calcium subtraction computed tomography angiography (CCTA) in patients with high calcium scores using invasive coronary angiography as the gold standard. Eleven patients with calcium scores of >400 underwent CCTA using a subtraction protocol followed by invasive coronary angiography. In addition to standard reconstructions, subtracted images were obtained using a dedicated subtraction algorithm. A total of 55 calcified segments were evaluated for image quality [using a 4-point scale ranging from 1 (uninterpretable) to 4 (good)] and the presence of significant (≥50 %) luminal stenosis. Conventional and subtracted CCTA were compared using quantitative coronary angiography (QCA) as the gold standard. The average image quality of conventional CCTA was 2.5 ± 0.6 versus 3.1 ± 0.6 on subtraction CCTA (P < 0.001). The percentage of segments with a score 1 or 2 was reduced from 41.8 to 12.7 % after coronary calcium subtraction (P = 0.002). On QCA, significant stenosis was observed in 16 segments. The area under the receiver operating characteristics curve to detect ≥50 % stenosis on QCA increased from 0.741 [95 % confidence interval (CI) 0.598–0.885] for conventional CCTA to 0.905 (95 % CI 0.791–1.000) for subtraction CCTA (P = 0.003). In patients with extensive calcifications undergoing CCTA, coronary calcium subtraction may improve the evaluation of calcified segments.     

Reduction in downstream test utilization following introduction of coronary computed tomography in a cardiology practice

To compare utilization of non-invasive ischemic testing, invasive coronary angiography (ICA), and percutaneous coronary intervention (PCI) procedures before and after introduction of 64-slice multi-detector row coronary computed tomographic angiography (CCTA) in a large urban primary and consultative cardiology practice. We utilized a review of electronic medical records (NotesMD^®) and the electronic practice management system (Megawest^®) encompassing a 4-year period from 2004 to 2007 to determine the number of exercise treadmill (TME), supine bicycle exercise echocardiography (SBE), single photon emission computed tomography (SPECT) myocardial perfusion stress imaging (MPI), coronary calcium score (CCS), CCTA, ICA, and PCI procedures performed annually. Test utilization in the 2 years prior to and 2 years following availability of CCTA were compared. Over the 4-year period reviewed, the annual utilization of ICA decreased 45% (2,083 procedures in 2004 vs. 1,150 procedures in 2007, P < 0.01) and the percentage of ICA cases requiring PCI increased (19% in 2004 vs. 28% in 2007, P < 0.001). SPECT MPI decreased 19% (3,223 in 2004 vs. 2,614 in 2007 P < 0.02) and exercise stress treadmill testing decreased 49% (471 in 2004 vs. 241 in 2007 P < 0.02). Over the same period, there were no significant changes in measures of practice volume (office and hospital) or the annual incidence of PCI (405 cases in 2004 vs. 326 cases in 2007) but a higher percentage of patients with significant disease undergoing PCI 19% in 2004 vs. 29% in 2007 P < 0.01. Implementation of CCTA resulted in a significant decrease in ICA and a corresponding significant increase in the percentage of ICA cases requiring PCI, indicating that CCTA resulted in more accurate referral for ICA. The reduction in unnecessary ICA is associated with avoidance of potential morbidity and mortality associated with invasive diagnostic testing, reduction of downstream SPECT MPI and TME as well as substantial savings in health care dollars.     

Assessment of image quality and radiation dose in prospective ECG-triggered coronary CT angiography compared with retrospective ECG-gated coronary CT angiography

We sought to determine the cut-off point of the average heart rate (HR) and HR differences in obtaining diagnostic image quality using prospective electrocardiographically-triggered (PT) coronary computed tomographic angiography (CCTA) and to compare image quality and radiation dose for CCTA obtained with PT CCTA and retrospective electrocardiographically-gated (RG) CCTA. A total of 178 patients who were referred for CCTA were enrolled in the study. Two independent radiologists evaluated subjective image quality. The non-diagnostic coronary segments were 32 of 1,226 segments (2.6%) for PT CCTA and 12 of 1,346 segments (0.9%) for RG CCTA (P < 0.001). The mean image quality scores for PT CCTA and RG CCTA were 3.82 ± 0.29 and 3.93 ± 0.14, respectively. The mean radiation dose of patients that underwent PT CCTA was 3.83 ± 0.84 mSv and RG CCTA 10.7 ± 2.70 mSv. For patients who underwent PT CCTA, image quality was inversely related to HR (56.5 ± 4.3 bpm; r = 0.38; P < 0.001) and HR differences (2.8 ± 2.7 bpm; r = 0.49; P < 0.001). With the use of receiver operator characteristic analysis, a cut-off HR of 57 bpm (58% sensitivity, 67% specificity) and HR difference of 6 bpm (93% sensitivity, 46% specificity) were the best threshold for the prediction of diagnostic image quality. In patients with a regular, low HR, PT CCTA offers diagnostic image quality and substantially reduces effective radiation compared with the use of RG CCTA with dose modulation.     

The impact of image resolution on computation of fractional flow reserve: coronary computed tomography angiography versus 3-dimensional quantitative coronary angiography

Calculation of fractional flow reserve (FFR) based on computational fluid dynamics (CFD) requires reconstruction of patient-specific coronary geometry and estimation of hyperemic flow rate. Coronary computed tomography angiography (CCTA) and invasive coronary angiography (ICA) are two dominating imaging modalities used for the geometrical reconstruction. Our aim was to investigate the impact of image resolution as inherently associated with these two imaging modalities on geometrical reconstruction and subsequent FFR calculation. Patients with mild or intermediate coronary stenoses who underwent both CCTA and ICA were included. CCTA images were acquired either by 320-row area detector CT or by 128-slice dual-source CT. Two geometrical models were reconstructed separately from CCTA and ICA, from which FFR_CTA and FFR_QCA were subsequently calculated using CFD simulations, applying the same hyperemic flow rate derived from the ICA images at the inlet boundaries. A total of 57 vessels in 41 patients were analyzed. Average diameter stenosis was 43.4 ± 10.8 % by 3D QCA. Reasonably good correlation between FFR_CTA and FFR_QCA was observed (r = 0.71, p < 0.001). The difference between FFR_CTA and FFR_QCA was correlated with the deviation between minimal lumen areas by CCTA and by ICA (ρ = 0.34, p = 0.01), but not with plaque volume (ρ = ?0.09, p = 0.51) or calcified plaque volume (ρ = 0.01, p = 0.95). Applying the cutoff value of ≤0.8 to both FFR_CTA and FFR_QCA, the agreement between FFR_CTA and FFR_QCA in discriminating functional significant stenoses was moderate (kappa 0.47, p < 0.001). Disagreement was found in 10 (17.5 %) vessels. Acceptable correlation between FFR_CTA and FFR_QCA was observed, while their agreement in distinguishing functional significant stenosis was moderate. Our results suggest that image resolution has a significant impact on FFR computation.     

Assessment of coronary in-stent restenosis: value of subtraction coronary computed tomography angiography

In conventional coronary computed tomography angiography (CCTA), metal artifacts are frequently observed where stents are located, making it difficult to evaluate in-stent restenosis. This study was conducted to investigate whether subtraction CCTA can improve diagnostic accuracy in the evaluation of in-stent restenosis. Subtraction CCTA was performed using 320-row CT in 398 patients with previously placed stents who were able to hold their breath for 25 s and in whom mid-diastolic prospective one-beat scanning was possible. Among these patients, 126 patients (94 men and 32 women, age 74 ± 8 years) with 370 stents who also underwent invasive coronary angiography (ICA) were selected as the subjects of this study. With ICA findings considered the gold standard, conventional CCTA was compared against subtraction CCTA to determine whether subtraction can improve diagnostic accuracy in the evaluation of in-stent restenosis. When non-assessable stents were considered to be stenotic, the diagnostic accuracy in the evaluation of in-stent restenosis was 62.7 % for conventional CCTA and 89.5 % for subtraction CCTA. When the non-assessable stents were considered to be non-stenotic the diagnostic accuracy was 90.3 % for conventional CCTA and 94.31 % for subtraction CCTA. When subtraction CCTA was used to evaluate only the 138 stents that were judged to be non-assessable by conventional CCTA, 116 of these stents were judged to be assessable, and the findings for 109 of them agreed with those obtained by ICA. Even for stents with an internal diameter of 2.5–3 mm, the lumen can be evaluated in more than 80 % of patients. Subtraction CCTA provides significantly higher diagnostic accuracy than conventional CCTA in the evaluation of in-stent restenosis.     

Direct comparison of stress- and rest-dual-energy computed tomography for detection of myocardial perfusion defect

We assessed the diagnostic performance of stress- and rest-dual-energy computed tomography (DECT) and their incremental value when used with coronary CT angiography (CCTA) compared with combined invasive coronary angiography (ICA)/cardiovascular magnetic resonance (CMR) for detecting hemodynamically significant stenosis causing a myocardial perfusion defect. Forty patients (30 men; mean age, 63.4 ± 8.8 years) with known or suspected coronary artery disease detected by CCTA underwent stress- and rest-DECT, CMR, and ICA. DECT iodine maps were compared with CMR on a per-segment and per-vessel basis. Diagnostic value of CCTA was assessed on a per-vessel basis before and after stress- and rest-DECT and compared to that of ICA/CMR. Compared to CMR, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of rest-DECT for detecting segment (vessel)-based perfusion defects were 29 % (46 %), 88 % (79 %), 56 % (61 %), and 70 % (67 %), respectively. Corresponding values using stress-DECT were 73 % (94 %), 83 % (74 %), 70 % (72 %), and 85 % (95 %), respectively. There was fair (κ = 0.39) agreement between rest- and stress-DECT iodine maps in identifying segments with perfusion defects. Compared with the ICA/CMR for identifying hemodynamically significant stenoses, per-vessel territory sensitivity, specificity, PPV, and NPV of CCTA were 91, 56, 55, and 91 %, respectively; those using CCTA/rest-DECT were 42, 83, 59, and 70 %, respectively; and those using CCTA/stress-DECT were 87, 79, 71, and 91 %, respectively. The area under the receiver operating characteristic curve decreased from 0.74 to 0.62 (P = 0.06) using CCTA/rest-DECT but increased to 0.83 (P = 0.02) using CCTA/stress-DECT. Stress-DECT has incremental value when used with CCTA for detecting hemodynamically significant stenoses.     

Prospective ECG-triggered sequential scan protocol for coronary dual-source CT angiography: initial experience

The exposure to ionizing radiation has raised concerns about coronary CT angiography (CCTA). Recently, prospective ECG-triggered sequential scan technique has been introduced in CCTA to significantly reduce radiation exposure. The purpose of this study was to analyze our experience with the sequential scan technique on a dual-source CT system with respect to image quality and radiation dose. Qualitative and quantitative image quality as well as radiation dose were assessed in 514 consecutive patients undergoing CCTA either with sequential or spiral image acquisition technique on dual-source CT. The selection of the applied scan technique was at the discretion of an experienced coronary CT angiographer. A multivariate logistic regression analysis was applied to identify predictors of diagnostic image quality. Diagnostic CCTA image quality was found in 1,395/1,429 (97.6%) versus 4,664/4,782 (97.5%) of the coronary segments in patients studied with sequential versus spiral scanning (P = 0.82). While the application of betablockers for CCTA was an independent factor for improved image quality in the multivariate regression analysis, heart rate variability and body mass index were indepentently associated with a deterioriated image quality. The scan technique had no independent impact on diagnostic image quality. Mean estimated radiation dose was reduced by 63% in patients studied with sequential scan technique (3.4 ± 2.2 vs. 7.6 ± 5.0 mSv, P < 0.01). In patients with a low and stable heart rate, the sequential scan technique is a promising method to effectively reduce radiation exposure in dual-source CCTA. Due to the comparable image quality in sequential and spiral dual-source CCTA, the sequential scan technique should be considered as the primary scan protocol in appropriate patients.     

Coronary CT angiography using the second-generation 320-detector row CT: assessment of image quality and radiation dose in various heart rates compared with the first-generation scanner

To assess the image quality and radiation dose reduction in various heart rates in coronary CT angiography using the second-generation 320-detector row CT compared with the first-generation CT. Ninety-six patients were retrospectively included. The first 48 patients underwent coronary CT angiography with the first-generation 320-detector row CT, while the last 48 patients underwent with the second-generation CT. Subjective image quality was graded using a 4-point scale (4, excellent; 1, unable to evaluate). Image noise and contrast-to-noise ratio were also analyzed. Subgroup analysis was performed based on the heart rate. The mean effective dose was derived from the dose length product multiplied by a conversion coefficient for the chest (κ = 0.014 mSv × mGy^?1 × cm^?1). The overall subjective image quality score showed no significant difference (3.66 vs 3.69, respectively, p = 0.25). The image quality score of the second-generation group tended to be higher than that of the first-generation group in the 66- to 75-bpm subgroup (3.36 vs 3.53, respectively, p = 0.07). No significant difference was observed in image noise and contrast-to-noise ratio. The overall radiation dose reduced by 24 % (3.3 vs 2.5 mSv, respectively, p = 0.03), and the reduction was substantial in patients with higher heart rate (66- to 75-bpm, 4.3 vs 2.2 mSv, respectively, p = 0.009; >75 bpm, 8.2 vs 3.7 mSv, respectively, p = 0.005). The second-generation 320-detector row CT could maintain the image quality while reducing the radiation dose in coronary CT angiography. The dose reduction was larger in patients with higher heart rate.     

Triple rule-out acute chest pain evaluation using a 320-row-detector volume CT: a comparison of the wide-volume and helical modes

The purpose of this study was to investigate the image quality and radiation dose of triple rule-out computed tomography (TROCT) using a 320-row-detector volume CT system to compare the wide-volume and helical modes of this CT system. Sixty-four patients with noncritical chest pain were allocated to one of 2 groups according to the type of CT examination mode used. Group 1 patients were examined using the wide-volume (non-spiral) mode and group 2 patients were examined using the 160-detector row helical mode, with the same contrast injection protocol in both methods [biphasic injection protocol; injection rate of 4 ml/s, median volume, 70 ml (range 65–100 ml)]. Attenuations of the pulmonary trunk, ascending aorta, and coronary arteries were measured in Hounsfield units; a subjective overall patient-based image quality score of 1–3 was awarded to each study. Effective doses, signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated. Average effective dose was significantly lower in group 1 than group 2 (9.7 ± 5.1 vs. 16 ± 5.9 mSv, P < 0.001). The mean attenuation of the main pulmonary trunk was significantly higher in group 1 than group 2 (P = 0.04) and mean attenuations in other vessels were not significant different. SNR and CNR were not significantly different between the groups. The proportion of diagnostic image qualities for chest CT angiography (CTA) was similar between the groups (93.5 vs. 93.9 %). In coronary CTA, group 1 showed a higher proportion of diagnostic image qualities than group 2 (100 vs. 87.9 %). The use of wide-volume mode of 320-detector CT reduces the overall effective radiation dose and results in similar attenuation and image quality for TROCT as compared with the helical mode.     

Validity of the size-specific dose estimate in adults undergoing coronary CT angiography: comparison with the volume CT dose index

Size-specific dose estimate (SSDE) takes into account the patient size but remains to be fully validated for adult coronary computed tomography angiography (CCTA). We investigated the appropriateness of SSDE for accurate estimation of patient dose by comparing the SSDE and the volume CT dose index (CTDI_vol) in adult CCTA. This prospective study received institutional review board approval, and informed consent was obtained from each patient. We enrolled 37 adults who underwent CCTA with a 320-row CT. High-sensitivity metal oxide semiconductor field effect transistor dosimeters were placed on the anterior chest. CTDI_vol reported by the scanner based on a 32-cm phantom was recorded. We measured chest diameter to convert CTDI_vol to SSDE. Using linear regression, we then correlated SSDE with the mean measured skin dose. We also performed linear regression analyses between the skin dose/CTDI_vol and the body mass index (BMI), and the skin dose/SSDE and BMI. There was a strong linear correlation (r = 0.93, P < 0.001) between SSDE (mean 37 ± 22 mGy) and mean skin dose (mean 17.7 ± 10 mGy). There was a moderate negative correlation between the skin dose/CTDI_vol and BMI (r = 0.45, P < 0.01). The skin dose/SSDE was not affected by BMI (r = 0.06, P > 0.76). SSDE yields a more accurate estimation of the radiation dose without estimation errors attributable to the body size of adult patients undergoing CCTA.     

The evolution and investigation of native coronary arteries in patients after coronary stent implantation: a study by 320-detector CT angiography

To study the role of 320-detector coronary computed tomography angiography (CTA) in assessing native coronary arteries in patients treated with coronary stents. 123 patients with coronary stenting received both CTA and conventional coronary angiography (CCA) within 1 day. The clinical parameters, coronary calcium scoring, CTA and CCA were analyzed to determine the prevalence of significant stenosis of native coronary arteries (SSNCA), the predictive value of CTA and the factors correlating with SSNCA and newly developed SSNCA after stenting (NDSSNCAS), with CCA as the standard of reference, using both vessel-based analysis (VBA) and patient-based analysis (PBA). Both the source and the reconstructed images were analyzed by CTA. All native coronary arteries were interpretable independent of cardiac motion. CTA showed a sensitivity/specificity of 93.5 %/97.3 % and 92.5 %/92.5 % in diagnosing SSNCA in VBA and PBA, respectively. The significant factors related to SSNCA were higher calcium scores (P = 0.003), a higher serum glucose level (P = 0.048), a greater number of vessels without previous stent placement (P = 0.003) and fewer stents implanted within the vessels (P = 0.003). The risk factors showed no significant correlation from PBA on SSNCA or from NDSSNCAS on either VBA or PBA. CTA demonstrates excellent correlation with CCA. The prevalence of SSNCA is significantly correlated with the presence of higher calcium scores in the arteries, a higher serum glucose level, a greater number of vessels without previous stent placement and fewer stents implanted within the vessels; PBA on SSNCA and NDSSNCAS on both VBA and PBA showed no significance.     

Image quality and radiation reduction of 320-row area detector CT coronary angiography with optimal tube voltage selection and an automatic exposure control system: comparison with body mass index-adapted protocol

To assess the image quality and radiation exposure of 320-row area detector computed tomography (320-ADCT) coronary angiography with optimal tube voltage selection with the guidance of an automatic exposure control system in comparison with a body mass index (BMI)-adapted protocol. Twenty-two patients (study group) underwent 320-ADCT coronary angiography using an automatic exposure control system with the target standard deviation value of 33 as the image quality index and the lowest possible tube voltage. For comparison, a sex- and BMI-matched group (control group, n = 22) using a BMI-adapted protocol was established. Images of both groups were reconstructed by an iterative reconstruction algorithm. For objective evaluation of the image quality, image noise, vessel density, signal to noise ratio (SNR), and contrast to noise ratio (CNR) were measured. Two blinded readers then subjectively graded the image quality using a four-point scale (1: nondiagnostic to 4: excellent). Radiation exposure was also measured. Although the study group tended to show higher image noise (14.1 ± 3.6 vs. 9.3 ± 2.2 HU, P = 0.111) and higher vessel density (665.5 ± 161 vs. 498 ± 143 HU, P = 0.430) than the control group, the differences were not significant. There was no significant difference between the two groups for SNR (52.5 ± 19.2 vs. 60.6 ± 21.8, P = 0.729), CNR (57.0 ± 19.8 vs. 67.8 ± 23.3, P = 0.531), or subjective image quality scores (3.47 ± 0.55 vs. 3.59 ± 0.56, P = 0.960). However, radiation exposure was significantly reduced by 42 % in the study group (1.9 ± 0.8 vs. 3.6 ± 0.4 mSv, P = 0.003). Optimal tube voltage selection with the guidance of an automatic exposure control system in 320-ADCT coronary angiography allows substantial radiation reduction without significant impairment of image quality, compared to the results obtained using a BMI-based protocol.     

Stent fracture and longitudinal compression detected on coronary CT angiography in the first- and new-generation drug-eluting stents

To evaluated prevalence and clinical implication of stent fracture and longitudinal compression in first- and new-generation drug-eluting stents (DES) using coronary computed tomography angiography (CCTA). The incidence of stent fracture and longitudinal compression were compared between first- and new-generation DES in 374 patients who underwent coronary stenting using DES and follow-up CCTA due to recurrent angina. 235 and 139 patients received 322 first- and 213 new-generation DES, respectively. The crude per-stent incidence of longitudinal compression (6.1 vs. 0.3 %, p < 0.001) was higher after new- than first-generation DES implantation using CCTA and the incidence of stent fracture (11.3 vs. 8.1 %, p = 0.23) was comparable. On follow-up coronary angiography for 347 stents, stent fracture (3.2 %) and longitudinal compression (0.9 %) were less detected than those on CCTA. Ostial stenting was a risk factor of longitudinal compression (p < 0.001). Stent fracture was associated with younger patients (p = 0.03), longer stent (p = 0.010), and excessively tortuous lesions (p = 0.001). The presence of stent fracture or longitudinal compression was not associated with poor clinical outcomes. The longitudinal compression more frequently occurred after new-generation DES implantation. The stent fracture was comparable between two DES. However, the occurrence of such mechanical deformities did not translate into a poor clinical outcome.     

Effect of kVp on image quality and accuracy in coronary CT angiography according to patient body size: a phantom study

The aim is to investigate the effect of tube voltage and chest wall thickness on image quality, stenosis measurement, and radiation dose in coronary CT angiography (CCTA) in a phantom study. A phantom with tubes in a box at its center and concentric cylindrical plastic chambers of three layers at its periphery was constructed. The concentric cylinders were filled with oil or left empty to simulate different degrees of obesity. Retrospective CT scanning was performed at different kVps and mAs. Image noise, contrast to noise ratio (CNR), stenosis measurement, and radiation dose were obtained. A CNR higher than 10 was considered to be acceptable for clinical practice. Mean image noise was 51.7 at 80 kVp, 31.6 at 100 kVp, and 24.7 at 120 kVp (P < 0.001). A CNR greater than 10 could be achieved with all the images using 80 kVp as well as using 100 or 120 kVp. However, CNRs at 100 and 120 kVp were significantly higher than the CNR at 80 kVp (P < 0.001). There were no significant differences between 100 and 120 kVp. All stenosis measurements were overestimated. Accuracy of stenosis measurement was significantly correlated with CNR (P < 0.05), but not with kVps. Mean doses were 2.07 mSv at 80 kVp, 3.37 mSv at 100 kVp, and 5.17 mSv at 120 kVp (P < 0.001). CNR per radiation dose was highest at 80 kVp, regardless of chest wall thickness. For CCTA, using 80 kVp with high mAs is the best choice, regardless of chest wall thickness, for minimal radiation dose and sufficient image quality.     

High-definition computed tomography for coronary artery stents: image quality and radiation doses for low voltage (100 kVp) and standard voltage (120 kVp) ECG-triggered scanning

The noninvasive assessment of coronary stents by coronary CT angiography (CCTA) is an attractive method. However, the radiation dose associated with CCTA remains a concern for patients. The purpose of this study is to compare the radiation doses and image qualities of CCTA performed using tube voltages of 100 or 120 kVp for the evaluation of coronary stents. After receiving institutional review board approval, 53 consecutive patients with previously implanted stents (101 stents) underwent 64-slice CCTA. Patients were divided into three different protocol groups, namely, prospective ECG triggering at 100 kVp, prospective ECG triggering at 120 kVp, or retrospective gating at 100 kVp. Two reviewers qualitatively scored the quality of the resulting images for coronary stents and determined levels of artificial lumen narrowing (ALN), stent lumen attenuation increase ratio (SAIR), image noise, and radiation dose parameters. No significant differences were found between the three protocol groups concerning qualitative image quality or SAIR. Coronary lumen attenuation and in-stent attenuation of 100 kVp prospective CCTA (P-CCTA) were higher than in the 120 kVp P-CCTA protocol (all Ps < 0.001). Mean ALN was significantly lower for 100 kVp P-CCTA than for 100 kVp retrospective CCTA (R-CCTA, P = 0.007). The mean effective radiation dose was significantly lower (P < 0.001) for 100 kVp P-CCTA (3.3 ± 0.4 mSv) than for the other two protocols (100 kVp R-CCTA 6.7 ± 1.0 mSv, 120 kVp P-CCTA 4.6 ± 1.2 mSv). We conclude that the use of 100 kVp P-CCTA can reduce radiation doses for patients while maintaining the imaging quality of 100 kVp R-CCTA and 120 kVp P-CCTA for the evaluation of coronary stents.     

Image quality and required radiation dose for coronary computed tomography angiography using an automatic tube potential selection technique

To investigate the image quality and the minimum required radiation dose for automatic tube potential selection (ATPS) in dual-source computed tomography (DSCT) coronary computed tomography angiography (CCTA). Three hundred twenty-five consecutive patients (153 men and 172 women) undergoing CCTA were assigned to either the ATPS group (n = 172) or the control group (n = 153); the control group underwent imaging at a constant current of 120 kV. All patients were scanned in either prospectively ECG-triggered high-pitch helical mode or sequential mode. The subjective image quality score, attenuation, image noise, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), volume CT dose index (CTDI_vol), and effective dose (ED) were compared between the two groups with the Student t test or Mann–Whitney U test. The subjective image quality score was not significantly different between the two groups. Imaging noise and attenuation were both significantly higher in the ATPS group than in the control group (imaging noise: 25.6 ± 7.6 versus 15.8 ± 4.0 HU, P < 0.001; attenuation: 559.6 ± 142.0 versus 412.5 ± 64.3 HU, P < 0.001). SNR and CNR were significantly lower in the ATPS group than in the control group (SNR: 23.21 ± 7.40 versus 27.71 ± 8.25, P < 0.001; CNR: 27.81 ± 8.44 versus 33.94 ± 9.69, P < 0.001). ED was significantly lower in the ATPS group than in the control group (ED: 1.25 ± 1.24 versus 2.19 ± 1.77 mSv, P < 0.001). For both groups, ED was significantly lower in the high-pitch mode than in the sequential mode. The use of ATPS for CCTA significantly reduced the radiation dose while maintaining image quality.     

Coronary in-stent restenosis: predisposing clinical and stent-related factors,diagnostic performance and analyses of inaccuracies in 320-row computed tomography angiography

The aim of this study was to identify predisposing factors for coronary in-stent restenosis (ISR) and assess its detection by 320-row computed tomography angiography (CTA) using invasive coronary angiography (ICA) as a gold standard. A total of 189 patients (aged 35–79, mean age 56.6, 169 males) with 318 stents underwent ICA within 4 days after CTA. ISR was found in 19 (10.0?%) patients and 25 (7.9?%) stents. At the patient level, the presence of ISR was significantly related to the number of deployed stents (P?=?0.026) and body mass index (P?=?0.030). At the stent level, stents with diameter <3 mm were more likely to have ISR than those with diameter ≥3 mm (53.8?% vs. 28.9?%, P?=?0.016). Bare metal stents were significantly more likely to have ISR than drug-eluting stents (15.2?% vs. 6?%, P?=?0.022). ISR was not significantly related to stent length (P?=?0.097) and stent placement in coronary arteries at the vessel level (P?=?0.059). False-positive or false-negative results of CTA were not related to stent location, diameter, length, and strut thickness (P?>?0.05). At the patient level, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of CTA for detecting ISR were 90, 96, 74, 99, and 96?%, respectively. At the stent level, the corresponding figures were 92, 96, 67, 99, and 96?%. The high negative predictive value of 99?% suggests that 320-row CTA is helpful for excluding ISR.     

High-pitch dual-source CT coronary angiography: analysis of the impact on image quality of altered electrocardiography waves during data acquisition

Electrocardiography (ECG) “altered waves” sometimes occur during data acquisition when computed tomography coronary angiography (CTCA) is performed with the prospectively ECG-triggered high-pitch (Flash spiral) mode using a second-generation dual-source CT. The aim of this study was to assess the effect of the ECG altered waves on image quality. Seventy-three consecutive patients with stable sinus rhythm ≤65 beats per minute were retrospectively enrolled in this study. CTCA was performed using the Flash spiral mode in which the data acquisition was prospectively triggered at 60 % of the R–R interval and completed within one cardiac cycle. The ECG waves before and during data acquisition were analyzed for grouping purposes. Image quality was evaluated using a four-point scale (1 = best, 4 = unevaluatable). Thirty patients (group 1) were found to have ECG altered waves during data acquisition, while 43 patients (group 2) had ECG “stable waves.” The altered waves were seen as the baseline drifting; the broad, erected, or inverted P wave or QRS complexes; and a new wave. However, the length of the R–R interval did not change during the data acquisition. There were no significant differences in image quality scores between the two groups on the per-patient (2 ± 0.87 vs. 2.2 ± 0.74, P = 0.273) or per-segment (1.27 ± 0.54 vs. 1.32 ± 0.55, P = 0.577) basis. There were no significant differences in coronary evaluatability as well (per-patient; 93.3 vs. 95.3 %, P = 0.352; per-segment; 99.4 vs. 99.6 %, P = 1.0). CTCA image quality is not affected by ECG altered waves during data acquisition using the Flash spiral mode in low and stable heart rate patients. Thus, the ECG altered waves are considered artifacts.     

Relation of coronary atherosclerosis and metabolic syndrome in asymptomatic subjects: evaluation with coronary CT angiography

To assess the relationship between metabolic syndrome (MetS) and coronary atherosclerosis using coronary CT angiography (CCTA) as the evaluation tool in asymptomatic cardiovascular disease (CVD) free subjects. The presence and extent of coronary atherosclerosis in 755 asymptomatic self-referred subjects were measured using CCTA. The relationships between coronary atherosclerosis, MetS, and other clinical factors were assessed. To further investigate the relationship between MetS and the presence and extent of coronary plaque, subjects were divided into 3 subgroups according to the number of metabolic factors (MF0, 1–2 or ≥3) and the number of coronary segments with plaque (segment involvement score: SIS0, 1, ≥2). MetS showed significant association with the presence of coronary plaque after adjustment for other clinical factors [odds radio (OR) 1.791 (1.159–2.775), P = 0.009]. Among metabolic components, abdominal obesity and high blood pressure were significantly associated with the presence of coronary plaque [OR 1.708 (1.189–2.455), P = 0.004; OR 1.677 (1.165–2.415), P = 0.005]. Coronary plaque was more frequently found in subgroups with a higher number of metabolic factors (32.4, 36.7 and 52.1 %). Higher SISs were also found in subjects with more MetS components (SIS1: 14.6, 16.2 and 27.2 %; SIS ≥ 2: 17, 19.7 and 23.7 %). In asymptomatic CVD free subjects, MetS and number of metabolic factors were related with an increased risk of the presence and the extent of coronary plaque. Abdominal obesity and high blood pressure were significantly associated with the presence of coronary plaque.     

Liver detection algorithm: its efficacy for CT noise reduction in the liver

Objectives

This study was performed to evaluate the efficacy of a novel computed tomography (CT) liver detection algorithm (LDA), which allows for targeted increase of radiation dose to the upper abdomen, on image quality of the liver.

Methods

We retrospectively evaluated the LDA by comparing 40 consecutive patients who had portal venous CT abdomen performed without use of the algorithm, to 40 patients in whom the algorithm was used. Image quality was assessed objectively by comparing the standard deviation (SD) of attenuation values in Hounsfield units (HU) of the abdominal organs. Qualitative analysis was performed by two blinded radiologists who independently graded the image quality of abdominal organs

Results

There was significant noise reduction in the liver (P < 0.001) and spleen (P < 0.001) in the LDA group compared to the conventional group. There was also a significant improvement in image quality of the liver (P < 0.001), kidney (P < 0.001), spleen (P < 0.001), pancreas (P < 0.001), and psoas (P = 0.005) in the LDA group compared to the conventional group. Overall dose between the two groups was similar.

Conclusions

This liver detection algorithm improves the subjective image quality of upper abdominal organs, in particular the liver, without increasing overall radiation dose.