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Education in Heart
Non-invasive imaging
Cardiac CT beyond coronary angiography: current and emerging non-coronary cardiac applications
  1. Milind Y Desai
  1. Correspondence to Dr Milind Y Desai, Tomsich Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, J1-5, 9500 Euclid Avenue, Cleveland, OH 44195, USA; desaim2{at}ccf.org

https://doi.org/10.1136/hrt.2009.184382

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    Within the last decade, non-invasive assessment of the coronary arteries using multidetector computed tomography (MDCT) has emerged as the newest application in diagnostic cardiology, leading to many technological advancements and substantial improvements in image acquisition and analysis.1 The early enthusiasm and rapid advancement has been tempered by concerns regarding increased radiation exposure, especially the wide range of radiation doses that a patient gets exposed to, for the same clinical indication.2 3

    However, in the last couple of years, the field of cardiac CT has made significant technological strides in areas of radiation reduction4 5 (prospective imaging, high pitch 100 kVp imaging, and electrocardiographic dose modulation), improved temporal resolution with dual source scanning6 (significantly improving cine imaging), increased supero-inferior coveragew1 (enabling single-beat imaging), improved injection protocols, and dual energy imaging (potentially enabling plaque characterisation).w2 As a result, the utility of MDCT can now be broadened to answer a multitude of clinical questions within cardiovascular medicine, albeit in conjunction with other non-invasive techniques such as echocardiography, myocardial perfusion scintigraphy, and cardiac magnetic resonance (CMR) imaging. Of course, the fundamental tenet of a new diagnostic modality is that its utilisation has to be matched with careful evaluation of appropriateness of a given indication, coupled with the knowledge that one diagnostic modality might be more appropriate than the other.1 This review of the current state-of-the art discusses the various non-coronary cardiac applications of MDCT, along with some of the emerging applications (box 1).

    Box 1

    Box 1 Various non-coronary cardiac indications of CT

    Current applications

    • Electrophysiology applications

      • Atrial fibrillation and pulmonary venous anatomy

      • Cardiac resynchronisation therapy and coronary venous anatomy

    • Reoperative cardiothoracic surgery

    • Valvular heart disease

      • Aortic valve

      • Mitral valve

      • Prosthetic valves

    • Transcatheter aortic valve implantation

    • Left ventricular systolic function

    • Pericardial diseases

      • Effusion

      • Constriction

    • Cardiac masses

      • Benign

      • Malignant

    • Non-ischaemic cardiomyopathies

    • Congenital heart disease

      • Simple and complex

    Emerging applications

    • Rest and stress myocardial perfusion

    • Viability assessment

      • Arterial phase

      • Delayed hyperenhancement

    • Molecular imaging

    Current non-coronary applications of cardiac MDCT

    MDCT in electrophysiology

    Atrial fibrillation

    Management strategies surrounding drug refractory atrial fibrillation generally revolve around electrical isolation of the pulmonary vein antrum (PVAI).w3 Delineation of pulmonary vein (PV) and left atrial anatomy is vital to the success of the procedure because of significant anatomic variabilityw4 (figure 1). Several studies have demonstrated that MDCT is equivalent or superior to intracardiac echocardiography, transoesophageal echocardiography (TOE) or reflux venography before PVAI.7 In addition, preprocedure imaging likely improves procedure times during PVAI and reduces overall radiation exposure by limiting fluoroscopy use.w5 Images can be acquired at very low radiation doses, especially with the advent of various radiation reduction techniques in MDCT.

    Figure 1
    Figure 1

    (A) Contrast enhanced multidetector computed tomography (MDCT) in a patient with atrial fibrillation demonstrating a widely patent left superior pulmonary vein before ablation. (B) Contrast enhanced MDCT in the same patient, 3 months after ablation, demonstrating significant stenosis of the left superior pulmonary vein.

    Another utility of MDCT (and also CMR) is in conjunction with electroanatomical mapping (EAM), which creates virtual three dimensional models of the left atrial anatomy and track catheter movements in real time. MDCT offers an ideal digital imaging platform for integration with EAM catheter guidance technology.w6

    Acquired PV stenosis is a rare but serious complication of PVAI, which is difficult to diagnose clinically. Currently, it is recommended to screen for PV stenosis at 3–6 months after an initial PVAI,w7 with serial follow-up in patients with documented stenosis (figure 1). MDCT is also useful to monitor patients after PV stenting as many patients develop symptomatic in-stent restenoses.

    While TOE remains the gold standard for assessment of left atrial appendage thrombus, MDCT has been demonstrated to have a high sensitivity and negative predictive value for thrombus detection, especially in patients undergoing PVAI (figure 2).8 w8 The disadvantage is that it is has a poor specificity and positive predictive value for differentiating between slow flowing blood and thrombus. Different techniques, including attenuation assessment, and repeating a delayed scan can significantly improve the accuracy.

    Figure 2
    Figure 2

    Contrast enhanced MDCT in a patient with atrial fibrillation demonstrating a filling defect in the left atrial appendage, highly suggestive of a thrombus.

    Cardiac resynchronisation therapy

    In cardiac resynchronisation therapy (CRT), endocardial implantation of a left ventricular pacing lead is accomplished by accessing the lateral cardiac vein through the coronary sinus. The lateral wall veins are ideal for the placement of the left ventricular pacing lead, because they typically produce the optimal haemodynamic results during CRT. MDCT can provide detailed images of the coronary venous system, and aid in identification of several variations in coronary venous anatomy, some of which can render an endocardial approach by the coronary sinus difficult or impossible, or can lead to suboptimal resynchronisation.9

    MDCT in preoperative planning before cardiac reoperative surgery

    Over the last decade, we have seen a steady increase in the rate of complicated reoperative cardiac surgery. In fact, at the Cleveland Clinic it approaches close to 30% of all cardiac surgeries performed. Despite this trend, mortality and morbidity for such operations is steadily decreasing, approaching the level of first time cardiothoracic surgery, even in the presence of a higher than average preoperative risk score.w9 There are many potential reasons for these results, including surgical experience, improved surgical techniques, and use of comprehensive preoperative planning (including routine performance of MDCT). As part of an MDCT evaluation, we evaluate for the presence of the following high risk findings: adherence/proximity (<1 cm) of right ventricle or aorta to the chest wall, and bypass graft crossing midline within 1 cm in anteroposterior direction of (or adherence to) the sternum (figure 3).10 These descriptors are directed at preventing catastrophic haemorrhaging during resternotomy, secondary to injury of underlying patent bypass grafts, right ventricle, and aorta, which had historically been reported to occur in 2–6% cases during sternal re-entry, with documented mortality of 37%.w10 Knowledge gained from preoperative imaging is necessary to plan the potential use of preventive surgical strategies, such as timing and approach to cannulation and cardiopulmonary bypass (with or without hypothermic circulatory arrest).w9

    Figure 3
    Figure 3

    Contrast enhanced MDCT in a patient with a prior history of coronary artery bypass grafting, who is being worked up for a redo cardiac surgery. Image demonstrates an aortocoronary graft in very close proximity to the sternum.

    In a recent study, we demonstrated a significant association between findings of high risk features on MDCT and use of preventive surgical strategies in high risk individuals undergoing reoperative cardiac surgery, with excellent 30 day outcomes.10 In another study of reoperative cardiac surgery patients, use of MDCT was associated with shorter perfusion and cross clamp time, shorter intensive care unit stays, and less frequent perioperative myocardial infarction.w11

    MDCT assessment of cardiac valves

    While echocardiography and CMR remain the mainstays of valvular assessment, in recent years MDCT is finding increasing utility in valvular assessment. Using the retrospective mode of scanning, it is possible to obtain a dataset over all the phases of the cardiac cycle, which in turn enables looping of the images in a cine format.

    Using this mode of scanning, assessment of cusp excursion and estimation of aortic valve area can be easily performed (supplementary movie 1). In patients with aortic stenosis, measurement of the aortic valve area on MDCT correlates significantly with that measured with echocardiography.11 Other CT findings of aortic stenosis include thickening and calcification of the leaflets. Quantification of aortic valve calcification can be performed, and the level of calcification severity is directly associated with severity of aortic stenosis.w12 Compensatory changes such as left ventricular hypertrophy and post-stenotic dilatation of the ascending aorta can be visualised. MDCT can detect aortic insufficiency by visualising the mal-coaptation of the cusps in end-diastolic phases.

    To assess mitral stenosis, the mitral valve area is measured in an early diastole phase. With the use of MDCT, the mitral valve area is reproducible and correlates well with echocardiography.w13 MDCT usually offers excellent visualisation of mitral valve morphology, thickening, and calcification (figure 4).w14 Secondary findings such as left atrial enlargement, thrombus formation, pulmonary oedema, and right ventricular hypertrophy are also seen. Recently, the potential utility of MDCT in planning for percutaneous mitral annuloplasty has been demonstrated.12 w15 MDCT provides useful information by depicting the relationship between the coronary sinus, mitral annulus, and coronary arteries. We also routinely perform MDCT to assess the size and degree of calcification of the pelvic vasculature before robotic mitral valve repair.

    Figure 4
    Figure 4

    Contrast enhanced MDCT in a patient with significant mitral regurgitation, being considered for possible robotic mitral valve surgery. Images reveal severe posterior mitral annular calcification.

    Another emerging indication for MDCT is assessment of prosthetic valves, as echocardiography and CMR can prove challenging in such cases due to excessive metal shielding artefacts (supplementary movie 2). With the use of appropriate window and level settings and cine images, mechanical leaflet motion and opening angle can be determined by MDCT.13 In addition, it can depict prosthetic complications, including ‘frozen’ leaflets from thrombus or pannus, valve dehiscence, pseudoaneurysm, infective endocarditis, or paravalvular abscess.

    MDCT in transcatheter aortic valve implantation

    Valve replacement is the only effective treatment for advanced aortic stenosis. However, there are significant numbers of patients who are not considered candidates for surgical aortic valve replacement because of high operative risk secondary to advanced age and/or comorbidities. For such patients, more recently, several transcatheter aortic valve implantation (TAVI) techniques have been developed using either a retrograde transfemoral or a transapical approach.w16 w17 This approach has an inherently different preoperative imaging work-up as compared to the open approach. For successful TAVI, it is extremely important to understand the complex anatomic relationships of the left ventricular outflow tract, aortic annulus, aortic root, and coronary arteries.14 Because of the lack of direct exposure during the procedure, the operator has to rely increasingly on pre- and intra-procedural imaging data. Recent developments of high resolution, contrast enhanced MDCT enable us to elicit such associations with precise accuracy, in unlimited three dimensional imaging planes.14 MDCT delineates the precise shape of the aortic annulus, which is often elliptical.14 It further gives a detailed look of the degree and location of valve leaflet calcification (allowing us to correlate the pattern of valve opening with leaflet anatomy) (figure 5). The precise relationship between the coronary ostia and the aortic annulus, which would enable optimal deployment of the valve, is well delineated by MDCT (supplementary movie 3).14 In addition, three dimensional analysis allows understanding of the relationship of the aortic root to the body axis for the planning of surgical or interventional access planes, by predicting two dimensional angiographic projections orthogonal to the aortic valve annulus, simplifying the insertion of percutaneous valves.15 Finally, visualisation of the aorta and the pelvic branches for minimal luminal diameter and degree of calcification is vital for reducing the peri-procedural complications.w18

    Figure 5
    Figure 5

    Contrast enhanced MDCT in a patient with severe aortic stenosis undergoing evaluation for possible transcatheter aortic valve implantation. Panel A demonstrates severely calcified trileaflet aortic valve in short axis. Panel B demonstrates the close relationship between the aortic annulus and the left main coronary artery take-off.

    MDCT assessment of left ventricular function

    While there are many techniques available to assess left ventricular (LV) function, no single technique is perfectly suited in all clinical situations. Cine MDCT can be potentially utilised to assess LV function in cases where either echocardiography or CMR is suboptimal or cannot be performed.1 In addition, it can be utilised for assessment of complex LV morphology before contemplated surgery, especially in complications of ischaemic heart disease such as an LV pseudoaneurysm (figure 6). Using the retrospective mode of scanning, four dimensional functional data can easily be obtained for assessment of LV function and volumes. However, in the current era of radiation concerns, it needs to be noted that this comes at the expense of significantly higher radiation (as compared to the prospectively triggered scans). Hence, routine measurement of LV function as part of a standard coronary CT acquisition is not recommended.

    Figure 6
    Figure 6

    Contrast enhanced MDCT in a patient with severe coronary artery disease and ischaemic cardiomyopathy. Four chamber multiplanar reformatted view demonstrates free wall rupture of the left ventricle with a large pseudoaneurysm.

    MDCT and the pericardium

    In the evaluation of pericardial disease, tomographic modalities are generally used as adjuncts to echocardiography.

    Advantages of tomographic modalities (in general and MDCT in particular) are highlighted in box 2.

    Box 2

    Box 2 Advantages of MDCT in pericardial disease

    • Excellent delineation of the pericardial anatomy

    • Delineation of pericardial calcification

    • A larger field of view, allowing the examination of the entire chest

    • Delineation of lung and mediastinal abnormalities in patients' other disorders like tuberculosis and radiation

    Pericardial effusion

    Tomographic imaging is indicated when loculated or haemorrhagic effusion or pericardial thickening is suspected or when findings at echocardiography are inconclusive. MDCT attenuation measurements also enable the initial characterisation of pericardial fluid. Attenuation values greater than that of water suggests malignancy, haemopericardium, purulent exudate, hypothyroidism or chylopericardium. When an effusion is secondary to malignancy, an irregularly thickened pericardium or pericardial nodularity may be depicted. Pericardial cysts usually have thin smooth walls without internal septa, with the same attenuation as water.

    Constrictive pericarditis

    Constrictive pericarditis is characterised by restricted ventricular filling leading to an increase in diastolic pressure and equalisation of right and left atrial and ventricular pressure. However, it needs to be differentiated from restrictive cardiomyopathy as patients with constrictive pericarditis might benefit from pericardial stripping. While Doppler echocardiography is excellent for delineating the physiologic basis of constriction, tomography is more accurate in the depiction of pericardial thickening and calcification (which can be focal). Pericardial thickness of 4 mm or more indicates abnormal thickening and, when it is accompanied by clinical findings of heart failure, is highly suggestive of constrictive pericarditis. Neither pericardial thickening nor calcification is diagnostic of constrictive pericarditis unless the patient also has symptoms of physiologic constriction. The central cardiovascular structures may show a characteristic narrow tubular configuration, along with a characteristic diastolic septal bounce on cine imaging (supplementary movie 4). Systemic venous dilatation, hepatomegaly, and ascites also are frequently seen.

    MDCT in assessment of cardiac masses

    Primary cardiac tumours are rare entities with an autopsy frequency of 0.19–0.56%.w19 w20 Only a quarter of these tumours are malignant, 95% of which are sarcomas. In general, besides their variable prevalence in particular age groups, cardiac tumours also differ with regard to their gender predilection, location, and number. Generally, echocardiography is used to make the initial diagnosis. However, tomographic imaging provides the following incremental value, as outlined in box 3.

    Box 3

    Box 3 Incremental value of tomographic imaging in cardiac masses

    • Detect additional lesions

    • Aid in tissue characterisation

    • Diagnose or exclude invasiveness

    • Evaluate the neighbouring structures for additional pathology

    While CMR is the preferred tomographic modality, MDCT can be extremely useful in many instances. MDCT, in particular, is useful for the evaluation of calcification and fat content within a mass. Also, use of attenuation measurements can further aid in tissue characterisation. Furthermore, MDCT of the chest is useful in the staging of malignant tumours.

    Benign tumours

    Myxomas, the most common benign tumours, are generally well characterised by echocardiography. Following contrast, on MDCT it appears as a well defined, low attenuation, intracavitary mass, with lobular contours (figure 7). Heterogeneity is a common feature of myxomas and reflects haemorrhage, necrosis, and calcification. In the case of lipomas (the second most common tumours), MDCT shows homogeneous, well circumscribed, low attenuation masses either in a cardiac chamber or in the pericardial space. Fibromas are commonly seen in infants and young children and appear as homogeneous masses with soft tissue attenuation. Rhabdomyomas, also seen in young children, typically originate within the ventricular myocardium and can regress spontaneously. Haemangiomas intensely enhance following contrast administration. Papillary fibroelastomas, because of excessive mobility, are best visualised by echocardiography; however, larger lesions can be seen using MDCT.

    Figure 7
    Figure 7

    Contrast enhanced MDCT in a patient with a suspected cardiac mass. Four chamber multiplanar reformatted view demonstrates a large mass in the left atrium, with benign characteristics, suggestive of a myxoma.

    In addition to primary cardiac masses, MDCT is also useful in the assessment of cardiac thrombi, which have a typical layered appearance with attenuation values ranging from 30–70 HU (Hounsfield units), depending upon the chronicity (figure 8).

    Figure 8
    Figure 8

    Contrast enhanced MDCT in a patient with chest pain and suspected coronary artery disease. Four chamber multiplanar reformatted view demonstrates a layered mass at the apex of the left ventricle, which is consistent with a thrombus.

    Malignant tumours

    Metastases to the heart are much more common than primary involvement, with an estimated ratio of 30:1.w20 These have a heterogeneous appearance on MDCT and often are associated with nodular thickening of the pericardium associated with haemopericardium.

    Sarcomas are the most common malignant cardiac tumours, of which angiosarcomas comprise 37% of the cases. MDCT often shows the presence of a low attenuated mass in the right atrium, with associated metastases to the lungs, which might be irregular or nodular, with invasive characteristics. Other sarcomas affect the left atrium more frequently, which is an important differentiating feature (figure 9). Primary cardiac lymphomas are extremely rare, presenting as solid, infiltrative tumours in one or multiple chambers of the heart. CT images show cardiac lymphomas as hypo- or iso-attenuated infiltrative soft tissue masses as compared with the myocardium, and the masses demonstrate heterogeneous enhancement after the administration of a contrast agent.16

    Figure 9
    Figure 9

    Contrast enhanced MDCT in a patient with a suspected cardiac mass. Four chamber multiplanar reformatted view demonstrates multiple masses, with infiltrative characteristics, including a broad based attachment at the roof of the left atrium. It was diagnosed on biopsy as a sarcoma.

    MDCT in non-ischaemic cardiomyopathies

    Echocardiography and CMR remain the mainstays in the diagnosis of various non-ischaemic cardiomyopathies, because of the complimentary and incremental information provided about regional and global LV function and tissue characterisation. However, occasionally, due to increasing use of devices and CMR incompatibility, MDCT (with or without cine images) might have a role in morphologic assessment of diseases, especially if echocardiographic images are not completely diagnostic.1 In hypertrophic cardiomyopathy it can provide precise measurements of LV thickness and papillary muscle morphology. Similarly, in non-compaction or restrictive cardiomyopathies, it can precisely delineate the LV morphology, trabeculations, and also detect thrombus.w21 In arrhythmogenic right ventricular cardiomyopathy, it can provide accurate measurement of right ventricular size, systolic function, and delineate fatty infiltration of the free wall (figure 10).17

    Figure 10
    Figure 10

    Contrast enhanced MDCT in a patient with a history of syncope and a family history of sudden cardiac death. Four chamber multiplanar reformatted view of a severely dilated right ventricle, with thin walls and fatty infiltration, consistent with arrhythmogenic right ventricular cardiomyopathy.

    MDCT of congenital heart disease

    Echocardiography and CMR are the mainstays of diagnosis for assessment of patients with congenital abnormalities. However, because of various reasons, CMR ceases to be an option and alternative tomographic imaging such as MDCT becomes a necessity (figures 11 and 12). MDCT examination of a patient with congenital heart disease requires significant attention to the patient history.18 Unlike CMR, in which repeated acquisitions can be performed only at the cost of examination time, MDCT involves exposure to ionising radiation and potentially nephrotoxic contrast that need not be repeated with sufficient prescan planning. A detailed discussion of all imaging protocols is beyond the scope of this article.

    Figure 11
    Figure 11

    Contrast enhanced MDCT in a patient with congenital heart disease. Multiplanar reformatted view is suggestive of tetralogy of Fallot with an overriding aorta and a ventricular septal defect. Notice the dense material in the septal defect, likely a ruptured patch repair. Other typical features of tetralogy are not visualised in the current study.

    Figure 12
    Figure 12

    Contrast enhanced MDCT in a patient with congenital heart disease. Multiplanar reformatted view is suggestive of L-transposition (congenitally corrected) of the great arteries. Left atrium (LA) drains into the systemic ventricle (SV) which is the morphologic right ventricle (confirmed by the presence of trabeculations and moderator band), which drains into the aorta (Ao). Notice that the patient has a pacemaker and hence a CMR was not performed.

    However, the rules that need to be adhered to are shown in box 4.18

    Box 4

    Box 4 Principles of MDCT scanning in congenital indications

    • The extent of anatomic coverage for the scan should be based on detailed history and information of prior procedures

    • Adjust the scan parameters to minimise the amount of radiation while providing sufficient spatial resolution for the structures of interest

    • Need to optimally time the contrast delivery to adequately opacify the structures of interest

    • Systematic image analysis, which begins with deciding whether the atrial, ventricular, and arterial segments are concordant or discordant

    Emerging applications of cardiac MDCT

    Rest and stress perfusion assessment by MDCT

    Myocardial perfusion imaging adds incremental prognostic value beyond the invasive coronary angiogram, with quantification of ischaemia enabling risk stratification of patients for medical versus invasive therapies.w22 MDCT can detect a morphologic stenosis of the coronary artery, along with its potential functional significance. Recently, several studies have demonstrated the feasibility and good accuracy of pharmacologic stress MDCT in detection of ischaemic myocardium.w23 w24 Subsequent studies of adenosine mediated stress dual source CT have also demonstrated the feasibility and high accuracy of a CT protocol that combines stress and rest perfusion imaging together with coronary CT angiography in a single examination.19 20 We certainly need to ascertain the appropriateness of this indication with longer term studies, along with the radiation burden (∼12–13 mSV). The notion of performing perfusion CT in a high risk patient is very debatable, and the likely appropriate scenario appears to be in an intermediate risk population.

    Viability assessment by MDCT

    In ischaemic heart disease, precise assessment of myocardial viability is crucial for prediction of functional recovery following revascularisation as well as prognostication. Because of a variety of shortcomings in other technologies (echocardiography, CMR, and nuclear scintigraphy), MDCT is rapidly emerging as a potential alternative method of providing viability data.

    Arterial phase contrast enhanced MDCT

    During arterial phase contrast enhanced MDCT imaging, along with visualising coronary and cardiac anatomy, we can identify areas of decreased blood flow, with a high degree of accuracy.w25 However, hypoattenuation on MDCT is fairly non-specific, likely requiring additional testing to differentiate further between aetiologies.

    Delayed hyperenhancement MDCT

    Similar to CMR, delayed hyperenhancement is also observed on MDCT imaging 5–15 min after the administration of iodinated contrast, as these agents are also primarily extracellular. In acute myocardial infarction, myocyte necrosis results in interstitial oedema and membrane rupture, which allows the contrast to diffuse into the intracellular space.w26 Chronic infarcts contain dense collagenous scar, which has an expanded volume of distribution for iodinated contrast. Prior reports have demonstrated delayed enhancement in experimental models of acute and chronic myocardial infarction using MDCT.w27 MDCT has comparable results to CMR in the detection and sizing of acute and chronic myocardial infarcts.w28 w29 Delayed hyperenhancement MDCT predicts recovery of function after revascularisation.21

    However, delayed MDCT requires a second CT examination and hence additional radiation exposure for the patient. It also requires a large contrast volume to achieve a contrast-to-noise ratio sufficient to differentiate normal and infarcted myocardium. Advances in radiation dose reduction, optimisation of contrast-to-noise ratio, and standardisation of image quantification will be required to further establish MDCT as a reliable, accurate method for viability imaging.

    Conclusions

    If used judiciously, MDCT, as a diagnostic modality, has a tremendous potential in all facets of cardiovascular medicine. This article highlights the fact that cardiac CT is not just coronary CT. With further refinements in technology, MDCT is poised to assume an even greater role, especially in the fields of perfusion, viability, and pre-procedural planning. However, the importance of appropriate utilisation at the lowest possible radiation dose cannot be underscored.

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    Acknowledgments

    I would like to thank Dr Paul Schoenhagen, my friend and colleague at the Cleveland Clinic, for his insightful editorial advice.

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    View Abstract

    Supplementary materials

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    • Supplementary Data

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    Footnotes

    • Competing interests In compliance with EBAC/EACCME guidelines, all authors participating in Education in Heart have disclosed potential conflicts of interest that might cause a bias in the article. The author has no competing interests.

    • Provenance and peer review Commissioned; internally peer reviewed.