Table Of ContentClinical Applications of Cardiac CT
Second Edition
Filippo Cademartiri • Giancarlo Casolo •
Massimo Midiri
Editors
Clinical Applications
of Cardiac CT
Second Edition
In collaboration with:
Erica Maffei
Sara Seitun
Chiara Martini
Giuseppe Tarantini
Francesco Prati
123
Editors:
Filippo Cademartiri
Cardiovascular Imaging Unit,
“Giovanni XXIII” Hospital,
Monastier di Treviso (TV), Italy
Giancarlo Casolo
Cardiology Unit,
Versilia Hospital,
Lido di Camaiore (LU), Italy
Massimo Midiri
DIBIMEF, Department of Radiology,
“P. Giaccone” University Hospital,
Palermo, Italy
In collaboration with:
Erica Maffei
Sara Seitun
Chiara Martini
Giuseppe Tarantini
Francesco Prati
ISBN 978-88-470-2521-9 ISBN 978-88-470-2522-6 (eBook)
DOI 10.1007/978-88-470-2522-6
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Preface to the Second Edition
The second edition of Clinical Applications of Cardiac CT is the result of 2 years of hard work.
The first edition was released in 2008 and there are several reasons for having a second edition
planned and published after 3 years. Without doubt the main reason is related to the rapid deve-
lopment of the technology comprising the subject matter of this book. Since we finalized the first
edition several things in the field of CCT (Cardiac Computed Tomography) have changed.
The technology has developed allowing for more robust and reliable scanning with significant
radiation dose reduction; newer applications have been introduced such as myocardial perfusion;
consistent data on the prognostic value of CCT have been published. Large trials have been
undertaken with the aim of better defining the clinical role of CCT in different contexts. We have
better insight into clinical applications, we know CCT is useful in many more fields than in the
past, and we also expect CCT to grow in functional imaging and begin to replace other imaging
modalities.
For all these reasons CCT is no longer the same, nor is the way we teach CCT. We therefore
decided to update the first edition on the basis of all these considerations and also in an attempt
to improve the structure and layout of the educational content. In doing so we have tried to
better focus the first section of the book on the clinical aspects related to CCT applications.
The next three sections, targets of coronary and non coronary imaging, CT semeiology and
technique respectively, have been revised and enriched with up-to-date information, while the last
two sections have been revised to take into account the changing clinical scenario for CCT.
We contacted several new authors from the Italian and international arena to further enrich the
contents of the book. We are happy and proud of the result and we think that, in addition to upda-
ting the book, there has been an improvement in the overall content and layout.
November 2011 Filippo Cademartiri
Giancarlo Casolo
Massimo Midiri
v
Acknowledgements
General Acknowledgements
A book, whether it is new or the second edition of an earlier one, is always a journey, sometimes
the journey is long and sometimes it is also arduous. But wherever it takes you it always allows
you to learn a lot about the topic you are dealing with. A good book is also the result of the coop-
eration between individuals and the expression of a certain network of knowledge.
As with the first edition, this volume is the result of a great deal of hard work by all of the
authors and many others. Over the past two years many people have been involved who con-
tributed in numerous ways to its completion.
In particular we would like to thank Springer-Verlag Italia in the persons of Antonella Cerri,
Donatella Nebulone and Elisa Geranio for having supported us with the utmost professionalism
in this project.
Many others provided ideas, energy and assistance and to them we would like to express our
most sincere gratitude.
Filippo Cademartiri
Giancarlo Casolo
Massimo Midiri
Personal Acknowledgements
As usual for me, I would like to thank Prof. Gabriel P. Krestin, who has been the architect of my
abilities in the subject matter of this volume. Without the fortunate meeting which allowed me to
work alongside him I would never have achieved the desired results. My personal thanks are also
due to the Erasmus Medical Center in Rotterdam, in the persons of Maja Thijse-Stemerdink,
Nico Mollet, Pim de Feyter, Koen Nieman, Annick Weustink and many others who contributed
to the training of many of the authors who participated in this volume.
I would then like to thank my co-editors (Massimo Midiri and Giancarlo Casolo) who are
exceptional individuals and professionals who share my same vision of the subject matter.
Thanks from the bottom of my heart to all of the “fellows” who had the patience to bear with
me in Rotterdam, in Parma, and in Monastier and then to participate in this undertaking.
Thanks to cardiologists, cardiac surgeons and all the clinicians for their collaboration and
critical appraisal which always serves for improvement. Thanks also to the open minded profes-
sionals who started appreciating the role and importance of CCT.
Thanks to my closest collaborators Erica Maffei and Chiara Martini, because they are still fol-
lowing me and helping me with several projects.
Filippo Cademartiri
vii
Foreword to the First Edition
For a very long time, radiologists have considered examination of the moving heart as the “holy
grail” of noninvasive imaging. Echocardiography – with its high spatial and temporal resolution
– has opened an entire avenue of possibilities for evaluating myocardial contractility or heart
valve function. However, echocardiography does not allow alterations of the coronary arteries to
be visualized. Similarly, magnetic resonance imaging and myocardial scintigraphy have proven
to be valuable techniques in assessing myocardial perfusion and function, even in complex disea-
ses. Despite these advances, invasive catheter angiography has remained the gold standard for
visualization of the coronary artery lumen. Introduction of multislice CT was a real breakthrou-
gh, approaching the capabilities of catheter angiography with its unprecedented technological
development from simultaneous data acquisition of 4 slices, through 16, 64, to over 300 slices in
a single gantry rotation. With temporal resolutions under 100 milliseconds currently feasible,
multislice CT comes close to catheter angiography for coronary lumen visualization.
That this technology could be implemented and optimized, that its value as well as its role in
the clinical workup of patients with suspected coronary artery disease could be assessed in less
than one decade, has only been possible due to the enthusiasm and hard work of many radiolo-
gists, cardiologists, and image processors in close collaboration with industrial engineers and
developers. Many of the pioneers of this technology have been members of multidisciplinary
teams. Their natural curiosity, spirit of innovation, mutual understanding in a supportive environ-
ment, and – last but not least – strong desire to benefit patients by improving healthcare have
been the key to their success.
In many institutions, the introduction of multislice coronary CT-angiography for research and
clinical purposes was overshadowed by turf battles between different specialties. At Erasmus
MC, the “Rotterdam Model” was developed and proved to be a fruitful ground for the advance-
ment of this technology. Under the leadership of Professor Pim de Feijter, a well-recognized car-
diologist and expert in cardiac imaging, the Departments of Radiology and Cardiology built a
communal, multidisciplinary group of medical specialists, research fellows, trainees and radio-
graphers. Over the years this group has hosted more than 50 radiologists and cardiologists from
all over the world and in all different stages of training.
The year 2000 witnessed the start of a very prized and meaningful collaboration with the ima-
ging community in Italy when Filippo Cademartiri, one of the editors of this book, arrived at
Erasmus MC. Since then, an entire generation of Italian residents and fellows have spent a year
in Rotterdam learning about and doing research on coronary CT angiography. These scientists
from Palermo, Rome, Parma, Trieste, Verona, Ferrara and Genoa have contributed with enthu-
siasm and hard work to the output of this very successful enterprise. Eight of these residents, as
well as some of their Dutch colleagues, have co-authored chapters in this book. The exchange of
scientific personnel over the years has led to strong ties and collaborations with many of their
mentors and colleagues, some of whom have also contributed to this book. On behalf of the enti-
re Erasmus MC as well as on a personal level, I am very proud and pleased to have established
these ties, many of which have become long lasting friendships.
ix
x Foreword to the First Edition
I would like to congratulate all the editors and authors of Clinical Applications of Cardiac CT
for having produced a comprehensive overview of the technique and clinical application of this
new diagnostic tool. It is a multifaceted, highquality work that will provide both present and futu-
re generations with an insight into this exciting and still developing area of medical imaging.
Rotterdam, July 2008 Prof. Gabriel P. Krestin
Chairman, Department of Radiology
Erasmus MC
University Medical Center Rotterdam
The Netherlands
Contents
Section I - Epidemiology and Clinical Assessment
1 Epidemiology of Coronary Artery Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Tessa S.S. Genders and M.G. Myriam Hunink
2 Physiology and Pathophysiology of Coronary Circulation . . . . . . . . . . . . . . . . . . . . 7
Andrea I. Guaricci, Luigi Di Biase, and Giancarlo Casolo
3 Subclinical Atherosclerosis and Primary Prevention . . . . . . . . . . . . . . . . . . . . . . . . . 15
Giuseppe Tarantini, Paolo Buja, and Michela Facchin
4 Chronic (Stable) Coronary Artery Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Giancarlo Casolo
5 Acute Coronary Syndrome: Clinical Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Paolo Buja and Giuseppe Tarantini
Section II - Targets of Coronary and non Coronary Imaging
6 Coronary Plaques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Antonio L’Abbate, Massimo Lombardi, and Gualtiero Pelosi
7 Myocardial Ischemia & Viability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Paolo G. Camici and Ornella Rimoldi
8 Left and Right Ventricular Function, Contractility, Geometry, and Mass . . . . . . . 69
Andrea I. Guaricci, Natale Daniele Brunetti, Roberta Romito, Giancarlo Casolo,
and Matteo Di Biase
9 Pulmonary Veins and Cardiac Veins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Maurizio Del Greco, Flavia Ravelli, and Massimiliano Marini
Section III - CT Semeiology
10 Heart Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Ludovico La Grutta, Giovanni Gentile, Giuseppe Runza, Massimo Galia,
Filippo Cademartiri, and Massimo Midiri
11 Calcium Score and Coronary Plaque . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Sara Seitun, Erica Maffei, Chiara Martini, Margherita Castiglione Morelli,
Anselmo A. Palumbo, and Filippo Cademartiri
xi
xii Contents
12 Coronary Artery Stenosis on Cardiac CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Sara Seitun, Erica Maffei, Chiara Martini, Margherita Castiglione Morelli,
and Filippo Cademartiri
13 Coronary Artery Stents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Francesca Pugliese, Katarzyna Gruszczynska, Ian Baron, Ceri L. Davies,
and Steffen E. Petersen
14 Evaluation of Bypass Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Riccardo Marano, Giancarlo Savino, Carlo Liguori, and Lorenzo Bonomo
15 Myocardial Viability and Stress Perfusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Tust Techasith, Brian Ghoshhajra, and Udo Hoffmann
16 Evaluation of Cardiac Volumetric and Functional Parameters . . . . . . . . . . . . . . . . 175
Giancarlo Messalli, Giuseppe Runza, Ludovico La Grutta, Erica Maffei, Chiara Martini,
Massimo Midiri, Jan Bogaert, and Filippo Cademartiri
17 Cardiac Veins and Pulmonary Veins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Maurizio Centonze, Giulia Casagranda, Maurizio Del Greco, Andrea Laudon,
Alessandro Cristoforetti, and Giandomenico Nollo
18 Collateral Findings on Cardiac CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Roberto Malagò, Camilla Barbiani, Andrea Pezzato, Ugolino Alfonsi, Erica Maffei,
Roberto Pozzi Mucelli, and Filippo Cademartiri
19 Reporting in Cardiac CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Erica Maffei, Chiara Martini, Udo Hoffmann, and Filippo Cademartiri
20 Training and Implementation in Cardiac CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Erica Maffei, Chiara Martini, and Filippo Cademartiri
Section IV - Technique
21 CT and CT Angiography - Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Erica Maffei, Chiara Martini, and Filippo Cademartiri
22 CT of the Heart: Scan Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Erica Maffei, Chiara Martini, and Filippo Cademartiri
23 Patient Preparation for Cardiac CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Erica Maffei, Chiara Martini, and Filippo Cademartiri
24 Contrast Material Administration in Cardiac CT . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Erica Maffei, Chiara Martini, and Filippo Cademartiri
25 Principles of Cardiac CT Scan Protocol Optimization . . . . . . . . . . . . . . . . . . . . . . . 247
Erica Maffei, Chiara Martini, and Filippo Cademartiri
26 Management of Radiation Dose in Cardiac CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
Erica Maffei, Chiara Martini, and Filippo Cademartiri
27 Artifacts in Cardiac CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Roberto Malagò, Andrea Pezzato, Camilla Barbiani, Ugolino Alfonsi, Erica Maffei,
Filippo Cademartiri, and Roberto Pozzi Mucelli
