Cardiac CT Made Easy An Introduction to Cardiovascular

Multidetector Computed Tomography, 3rd Edition

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 Contents
Foreword vii
Editors ix
Contributors xi

Section 1 Basics of Multidetector Computed Tomography (MDCT) 1

Chapter 1 Introduction to Cardiovascular MDCT Imaging 3
Chapter 2 CT Perspective of Normal Cardiovascular Anatomy 5
Chapter 3 Technical Aspects of Multidetector Computed
Tomography 19

Section 2 Clinical Cardiovascular Applications 37

Chapter 4 Cardiac Chambers and Myocardial Disease 39
Chapter 5 Pericardial Disease 59
Chapter 6 Valvular Heart Disease 69
Chapter 7 CT Planning and Guidance for Transcatheter
Interventions 79
Chapter 8 Coronary Arterial and Venous Disease 87
Chapter 9 Pulmonary Vascular Disease 117
Chapter 10 Aortic Disease 125
Chapter 11 Peripheral Artery Disease 159
Chapter 12 Cardiac Masses 163
Chapter 13 Adult Congenital Heart Disease 173

References 193
Index 205

v
 Foreword
Driven by constant technical improvement, cardiac Computed Tomography (CT) continues
to find ever broader applications in cardiology. From cardiovascular disease prevention
to the management of patients with suspected coronary artery disease, from the support
of electrophysiology procedures to coronary and structural interventions, and from the
emergency room to specialized clinics: many areas of cardiovascular care benefit from the
capability of cardiac CT to provide high-resolution anatomic and functional information.
There is no doubt that contemporary cardiology practice relies heavily on the imaging
information provided by CT and most certainly, applications of CT imaging in cardiovascular
medicine will continue to grow.
New CT technology, optimized acquisition protocols, dedicated image reconstruction
algorithms, and advanced image processing methods have introduced both increased
applicability, but also somewhat added complexity to cardiac CT. This is why the third edition
of Cardiac CT Made Easy comes at the right time. Written by clinical experts with enormous
experience, the book follows a clear and concise style and comprehensively covers all relevant
areas of coronary and vascular disease, heavily illustrated by representative images.
I would like to thank and congratulate the authors for the creation of this most welcome
third edition and for their contribution to the field. Readers across the world will benefit from
the clinically relevant information that is provided in such a succinct form. Ultimately, the
book will contribute to the further development of cardiac and vascular CT to enhance the
care of countless patients.

Stephan Achenbach, MD, FESC, FACC, MSCCT

Professor of Medicine
University of Erlangen
Erlangen, Germany

vii
 Editors
Paul Schoenhagen MD, is Professor of Radiology at Case Western University, Cleveland
Clinic Lerner College of Medicine. He is a staff physician in the Department of Diagnostic
Radiology and in the Department of Cardiovascular Medicine. His clinical interest is focused
on cardiovascular imaging with computed tomography and magnetic resonance imaging.
He received his initial clinical training in internal medicine and radiology in Stuttgart,
Germany. This was followed by a residency in internal medicine and fellowships in
cardiology and in cardiovascular tomography at Cleveland Clinic. Dr Schoenhagen
was appointed to Cleveland Clinic in 2003. He has published numerous original and
review articles in leading peer-reviewed journals. He has been invited to present his clinical
experience and research at medical symposia and conferences in Japan, China, Europe, and
nationally.

Frank Dong PhD, DABR, FAAPM, is a staff diagnostic physicist and an Associate Professor
of Radiology at the Cleveland Clinic. Dr Dong received his PhD in medical physics from the
University of Wisconsin-Madison. Dr Dong’s specialty is in the field of CT image quality, CT
radiation dosimetry, and diagnostic ultrasound. He has authored and co-authored 38 peer-
reviewed articles, 3 book chapters, 15 patents, and 88 national and international meeting
abstracts/presentations. His clinical research is focused on low contrast lesion detectability
with advanced CT reconstruction algorithms, as well as the impact of metal artefact reduction
on low contrast lesion detection using custom-designed arthroplasty phantom. Dr Dong is the
co-investigator of an industrially funded research project involving evaluation of image quality
and diagnostic efficacy of a photon counting CT (PCCT). He currently serves as the Director
for the American Association of Physicists in Medicine (AAPM) Diagnostic Review Courses.
He also serves as the AAPM representative to the writing group of the American College of
Radiology (ACR)–AAPM Technical Standard for CT Performance Monitoring. Dr Dong
is a Fellow of AAPM, a member of the American College of Radiology, and the Intersocietal
Accreditation Commission (IAC) CT Board of Directors.

ix
 Contributors
Lei Zhao MD Xiaohai Ma MD, PhD
Department of Radiology Department of Radiology
Beijing Anzhen Hospital Beijing Anzhen Hospital
Capital Medical University Capital Medical University
Beijing, China Beijing, China

xi
 Section 1
Basics of Multidetector Computed
Tomography (MDCT)
 1
Introduction to Cardiovascular
MDCT Imaging

The diagnostic use of computed tomography (CT) is based on seminal developments in the
field of physics during the 1970s.1,2 Since then, CT has matured into an established diagnostic
imaging modality across multiple specialties and has witnessed an exponential increase in
use.3 In cardiovascular medicine, newer generations of scanner technology have expanded
the diagnostic spectrum to include assessment of the large vessels (aorta, pulmonary artery),
myocardium, pericardium, cardiac valves, and coronary arteries. CT is used in the initial
diagnosis, treatment planning for standard or minimally invasive cardiothoracic surgery and
transcatheter interventions, and disease follow-up.4
Since the publication of the first edition of this book, almost two decades ago in 2006,
knowledge about this imaging modality has become ever more important for imaging
specialists and clinicians alike. This book is developed for readers from multiple clinical
specialties, who are learning about cardiovascular CT. It is intended to be a short practical
introduction with a focus on visual material, complementary to more detailed textbooks.5
The book describes the principles of multidetector computed tomography (MDCT) for
cardiovascular applications, practical aspects of scan acquisition and interpretation, clinical
indications and imaging protocols, and clinical findings of common cardiovascular disease
conditions. The comparison with other imaging modalities, such as conventional angiography,
intravascular ultrasound, magnetic resonance imaging, and echocardiography, allows
understanding of the strength and limitations of CT in the assessment of specific clinical
questions.
The basic concept of CT is the reconstruction of thin image slices from multiple projections
obtained by rotating an X-ray source and detector system around the patient. In the resulting
tomographic image, individual structures are differentiated by different image intensities
(Hounsfield units). The acquired slices from the entire covered scan range (z-coverage) are
combined into a three-dimensional (3-D) volume, which can be reconstructed along unlimited
oblique planes following the data acquisition using dedicated computer workstations.
The advantages of tomographic CT imaging are partially offset by the lower temporal
resolution (longer time required to obtain data) compared to e.g. angiography. Because of the
rapid, constant motion of the heart during the cardiac cycle, long acquisition times increase
cardiac motion artefact (image blurring). The development of dedicated cardiovascular CT
systems therefore required optimization of acquisition times and synchronization of imaging
acquisition with the cardiac cycle.
This was initially realized with electron-beam technology (EBCT),6 but these scanners were
subsequently replaced by MDCT. In MDCT systems, the gantry (X-ray tube and detector)
rotates rapidly around the patient (Figure 1.1). Initial single detector CT systems, introduced
in 1972 for body imaging, were limited by very slow rotation and long acquisition time. Fast
gantry rotation, thin collimated detector rows, ECG-synchronized imaging, and acquisition

DOI: 10.1201/9781003153641-2 3
Cardiac CT Made Easy

Figure 1.1 Multidetector CT technology (MDCT). A third-generation dual-source scanner,

photographed from the “control-room” (top panel), and with open cover showing the gantry (bottom
panel).

of multiple slices per gantry rotation have since allowed the development of modern
cardiovascular systems.7,8 Dual-source scanners, with two X-ray tubes/detector systems were
introduced in 2008, and allowed a 50% reduction in temporal resolution.9 Today, high-end
scanners permit rotation times as low as 250 ms, with resulting temporal resolution of 135 ms
(single source) and 66 ms (dual source). Modern systems acquire up to 320 slices per rotation
with a minimum collimated detector row width of 0.5 or 0.625 mm resulting in isotropic
spatial resolution below 0.5 mm.

4
 2
CT Perspective of Normal
Cardiovascular Anatomy

Because of the oblique orientation of the cardiovascular structures in the chest, cardiovascular
imaging depends on acquisition or reconstructions of defined standard image planes oblique
to the body axes (‘z-axis’). These include e.g. two-, three-, and four-chamber views of the left
ventricle (LV) and are well known from e.g. echocardiography. With two-dimensional (2-D)
imaging modalities (e.g. standard echocardiography, most magnetic resonance sequences,
and standard angiography), these image planes are obtained at the time of image acquisition
and cannot be modified at the time of review. For 3-D modalities (computed tomography,
3-D echocardiography, 3-D magnetic resonance imaging [MRI] sequences, and rotational
angiography) a 3-D data volume is acquired and oblique planes are reconstructed at the time
of image analysis at the workstation. The ability to reconstruct the data volume in unlimited
oblique planes is one of the strengths of CT and other 3-D modalities.
The image processing techniques most often used are 2-D multiplanar reformation
(MPR) and maximum intensity projection (MIP), 3-D shaded surface display (SSD) and
volume rendering (VR), and 4-D volume rendering.10 The quality of these reformatted
images depends on the in-plane and through-plane spatial resolution. If the through-plane
resolution or slice thickness is less than the in-plane resolution of axial images, oblique
reformation will be associated with a loss of spatial resolution compared with axial images.
It is also important to understand that advanced 3-D and 4-D displays of the CT data can
be associated with loss of image detail. Therefore, experienced CT readers typically form
their initial impression using the axial ‘source’ images and then supplement the review with
advanced 3-D images.

2.1 Axial CT Images

Because CT systems acquire data in the axial plane, these images have the highest spatial
resolution. Therefore, the initial step for the interpretation of CT images remains review of
the individual tomographic axial image slices. Experienced readers are able to gain a 3-D
understanding from this review.

2.1.1 Two-Dimensional Reformation

The strength of volumetric 3-D CT imaging is that image processing allows reformation in
unlimited planes not specified at the time of data acquisition. This is critically important for
cardiac imaging, because most cardiac axes are oblique to the axial plane. Interactive computer

DOI: 10.1201/9781003153641-3 5
Cardiac CT Made Easy

workstations allow the user to place orthogonal planes through the data set, creating sagittal
and coronal images. Further manipulation of the reformatted plane provides oblique images
following the orientation of cardiac structures, e.g. the LV or the aortic root. In addition, curved
planes that follow the course of tortuous vessels, e.g. the coronary arteries, can be created
automatically or by tracing the path of the vessel on the original axial images. The resulting
curved image displays the 3-D course of the vessel. However, the surrounding anatomy is
sometimes distorted in these images.
The axial ‘source’ image is a 2-D grey-scale image displaying all pixels in an individual
image slice with a given slice thickness chosen during image reconstruction. 2-D images
can be reconstructed in different formats at an arbitrary slice thickness. The simplest image
processing method for visualization is MPR. An MPR is a 2-D image displaying all pixels
in a chosen plane. The original CT values are preserved. Therefore, in a contrast-enhanced
MPR image, e.g. of a coronary vessel, both the high-intensity signal of the contrast-filled
lumen and the low-intensity signal of the vessel wall are represented. Another common
reconstruction technique is the MIP. In contrast to the MPR, the MIP is a 2-D image
displaying only the maximum-intensity pixels. Therefore, in a contrast-enhanced MIP
image of the coronary vessel, visualization of the lumen is optimized, but the wall
structures are not well seen. Because of their similarity to conventional angiograms, MIP
images are often used for CT angiography. However, only a part of the original CT data
are preserved, and specifically changes of the vessel wall including atherosclerotic plaque
may be missed.

2.1.2 Three-Dimensional Reformation

Volume-rendered (VR) techniques employ advanced 3-D image processing algorithms with
semitransparent visualization of superficial and deep contours. Each voxel is assigned a value
for opacity according to its CT number, such that lower-intensity tissues are more transparent
while higher-intensity tissues are more opaque. Therefore, the more opaque tissue is visible
through translucent tissue, creating depth perception. VR images allow the demonstration of
complex anatomy and appreciation of the spatial relationship between visualized structures.
Levels of opacity can be varied to alter the display of data as needed. In addition, the VR data
can be viewed at arbitrary angles, including the standard views of conventional coronary
angiography (right anterior oblique/ left anterior oblique [RAO/LAO], cranial/caudal). Colour
coding can also be used to enhance further the 3-D appearance.
Perspective volume rendering (pVR) provides virtual endoscopic views of the surface
of anatomic structures that are sufficiently contrasted from surrounding tissue.11 This
technique is used to visualize cavities or tubular structures accessible to endoscopes (e.g.
the colon or the bronchial tree). Although the clinical value is unclear, pVR can also be
applied to chambers of the heart or vascular structures, which can be viewed from within
the lumen.

2.1.3 Dynamic, ‘4-Dimensional’ Reconstruction

Retrospective ECG-gated spiral techniques and, to a more limited extent prospective
ECG-triggered sequential techniques on some systems, allow reconstruction of data for
functional assessment (e.g. ejection fraction calculation). Multiple image sets from different
phases in the cardiac cycle are reconstructed and combined into a cine loop to produce
a dynamic image set. These images allow qualitative assessment of, e.g. left ventricular

6
 CT Perspective of Normal Cardiovascular Anatomy

function, and dynamic visualization of the complete spatial 3-D data set (4-D imaging).
It is important to remember that these dynamic data sets reflect data from only one or
two heartbeats and therefore do not allow beat-to-beat assessment, which is a strength
of echocardiography. Further, the temporal resolution is inferior to echocardiography
and in particular thin, highly mobile structures are expected to be better visualized with
echocardiography.

2.1.3.1 Cardiac chambers

The left and right cardiac chambers are visualized in two-chamber, three-chamber, four-
chamber, and short-axis views (Figure 2.1).
⚫⚫ The two-chamber view of the LV is comparable to the RAO ventriculogram performed
during angiography (Figure 2.2). In contrast to angiography, CT (also MRI, and
echocardiography) visualize both the contrast-filled ventricular cavity and the
myocardial wall.
⚫⚫ The three-chamber view includes the left atrium, LV, and aortic root. It visualizes the
relationship between the LV, mitral valve, and left ventricular outflow tract (LVOT)
(Figure 2.3, left upper panel). It is also the basis to reconstruct additional images of
the aortic and mitral annulus

Figure 2.1 Standard views of the cardiac chambers. Standard planes for visualization of the cardiac
chamber are two-chamber (left upper panel), three-chamber (right lower panel), four-chamber (left lower
panel), and short-axis (right upper panel) views.

7
Cardiac CT Made Easy

Figure 2.2 Two-chamber view. The two-chamber view is comparable to the left ventriculogram in
the RAO projection, performed during angiography. The CT two-chamber view of the LV (lower panel)
visualizes both the contrast-filled ventricular cavity and the myocardial wall.

Figure 2.3 Three-chamber view. A typical three-chamber is shown in the left upper panel. The short-axis
view shows the mitral valve in diastole (right upper panel) and systole (left lower panel).

8
 CT Perspective of Normal Cardiovascular Anatomy

⚫⚫ The four-chamber view allows simultaneous assessment of left and right ventricles (LV
and RV), the atria (LA and RA), and the atrioventricular valves (mitral and tricuspid valve)
(Figure 2.4, left upper panel). Quantification of left and right ventricular function is
possible if data is acquired throughout the entire cardiac cycle (retrospective gating) and
reconstructed at end diastole and end systole.12

2.1.3.2 Central venous and pulmonary venous return

⚫⚫ Venous return from the upper and lower parts of the body drains via the superior vena
cava (SVC) and inferior vena cava IVC) drain into the right atrium (Figure 2.5). The
SVC and IVC extend in a cranial-caudal orientation. Therefore, simple review of the axial
images provides near cross-sectional images, frequently without need for additional 3-D
reconstructions.
⚫⚫ The coronary venous blood flow drains via the coronary sinus into the RA (Figure 2.6).
It originates at the inferior-medical aspect of the RA, and bifurcates into branches
extending parallel to the coronary arteries. The largest branch lies inferior to the LA, and
then extends as the great cardiac vein along the left AV groove (along the left circumflex

Figure 2.4 Four-chamber view. The four-chamber view (left upper panel) allows simultaneous
assessment of left and right ventricle, atria, and atrioventricular valves (mitral and tricuspid valve). If the CT
images are acquired in different phases of the cardiac cycle (retrospective gating), data reconstruction
allows display of systolic and diastolic images for functional analysis. Modern software allows automatic
segmentation of the LV/RV cavity. In this figure, LV endocardial and epicardial borders are identified. This
allows calculation of ejection fraction, LV volumes, and myocardial mass, as demonstrated in this figure.

9
Cardiac CT Made Easy

Figure 2.5 Central venous return – SVC and IVC. The superior and inferior vena cava drain into
the right atrium. Because the SVC and IVC are extended in a cranial-caudal orientation, review of the
axial images provides near cross-sectional images, frequently without the need for additional 3-D
reconstructions. This figure shows axial images at several levels in the SVC and IVC and the location
in a sagittal image.

Figure 2.6 Coronary sinus. The coronary sinus (asterisk) drains the coronary flow into the right atrium.
This figure shows the close relationship to the left atrium.

artery [LCX]) to the anterior interventricular groove (parallel to the left anterior
descending artery [LAD]).
⚫⚫ Venous return from the lungs drains via the pulmonary veins into the LA. Each lung
lobe has separate drainage, which merge centrally. There are typically two left veins, the

10
 CT Perspective of Normal Cardiovascular Anatomy

Figure 2.7 Pulmonary veins. Venous return from the lungs drains via the pulmonary veins into the
left atrium. The upper left and upper middle panels show axial and sagittal images with the cross-hair
centred on the left superior vein. In the upper right panel, the planes are tilted through the left upper and
lower veins, resulting in an oblique axial image showing both veins (lower middle panel). The lower right
panel shows a volume-rendered image of the pulmonary veins.

left superior and left inferior and the left lingua lobar branch typically originates from
the left superior vein. Frequently there is a common antrum or stem of the left veins. In
most patients there are two right veins, the right superior and the right inferior vein. The
right middle lobe vein is typically a branch of the right superior vein and less frequently
drains separately into the LA. Initial review in axial and sagittal images provides a good
overview. If necessary, dedicated reconstructions along individual veins can be obtained
and also visualized with volume-rendered images (VRIs) (Figure 2.7).

2.1.3.3 Pulmonary artery

The RV connects via the right ventricular outflow tract (RVOT) with the pulmonary artery (PA).
The pulmonary valve lies at the transition between the RVOT and PA. The normal pulmonary
valve is typically not well seen due to the thin, mobile leaflets. The central PA bifurcates into the
right and left main vessels before further branching in the lungs (Figure 2.8). Depending on
the timing of the contrast bolus, the vascular tree with smaller segmental and sub-segmental
branches is visualized.

2.1.3.4 Aorta
2.1.3.4.1 Aortic root
The aortic root is a transition zone between the LVOT and tubular ascending aorta.
⚫⚫ The anatomic transition between the LVOT (Figure 2.9) and root is the crown-shaped
insertion of the aortic valve leaflets. By imaging, the aortic annulus/annular plane is defined
by the lowest insertion point of the aortic valve leaflets (Figure 2.9). Precise measurement

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Cardiac CT Made Easy

Figure 2.8 Pulmonary artery. The pulmonary valve lies at the transition between the RVOT and PA.
The central pulmonary artery bifurcates into the right and left main vessels before further branching in the
lungs. This figure shows axial (upper left and upper middle) and sagittal images (upper right) of the central
pulmonary artery. In the lower panels, oblique images are reconstructed at the level of the pulmonary valve.

Figure 2.9 Aortic root, LVOT. The transition between the LVOT and root is the aortic annulus. The
annulus anatomically has the shape of a crown. By imaging, the ‘annular plane’ is defined by the lowest
insertion point of the aortic valves. Precise measurement of the aortic annulus with minimal and maximal
diameter, circumference, and area is critically important for the evaluation in the context of TAVR.

12