Heart Vision. GP CME, Dunedin August Workshop 72 Saturday 4.30pm Edgar Centre. Dr R J Keenan CRG 2007
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1 Heart Vision GP CME, Dunedin August 2012 Workshop 72 Saturday 4.30pm Edgar Centre Dr R J Keenan CRG 2007 R J Keenan CRG 2010
2 Disclosures: 1. Pacific Radiology Group (PRG) - partner 2. Heart Vision - MD 3. General Electric - R&D partner Dr R J Keenan CRG 2007 Dr R J Keenan CRG 2012
3 Clinical MB. ChB. (Otago), FRANZCR (1991) Paediatric Imaging Fellowship (1992) Neuroimaging Fellowship ( ) Cardiac MR Adelaide (ACI) (2000) Cardiac CT Adelaide (ACI) (2002) CRG Partner - CHC Hospital Appt. (2004) Heart Vision CHC (2007) Cardiac CTA Specialist (2010) CT-PET Specialist application (2012) R J Keenan CRG 2012
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5 R J Keenan CRG
6 HEART VISION Ltd. joint venture CHRISTCHURCH RADIOLOGY GROUP & HEART CENTRE (2003) R J Keenan CRG 2012
7 Cardiac Imaging Team Right to Left: Amanda, Jo, Dr Latham Berry, Dr Sharyn Macdonald, Dr Ross Keenan, Jenny, Clare, Rachel Dr R J Keenan CRG 2012
8 Cardiac Imaging Team Heart Vision : Heart Vision reception, St Georges Radiology, Christchurch
9 Cardiac Imaging Team Heart Vision : Dr Latham Berry, Cardiac Radiologist, Jane Turner Cardiac CT technologist
10 Cardiac CT Imaging Systems Siemens Dual Source CT: Left: Definition 2007 (St Georges), Right: Definition FLASH 2012 (Christchurch Hospital)
11 Cardiac CT Imaging Systems Left: CCTA Syngo via VR Right: Syngo via curved MIP, normal LAD
12 Cardiac CT Imaging Systems Heart Vision : Dr Sharyn Macdonald, Cardiac Radiologist: Siemens Dual Source Definition CT_Circulation analysis
13 Cardiac CT : Heart Vision - based in St Georges Radiology CHC - total CCTA patients ~ 1900pts - CCTA v catheter ongoing audit - continuous radiation dose audit - health insurance coverage CACS screening not covered CCTA - SXHI criteria v others R J Keenan CRG 2012 Dr R J Keenan CRG 2007
14 HEART VISION R J Keenan CRG 2010
15 Outline CT radiation dose CACS - CT coronary calcium scoring CCTA - coronary CTA CMRI - cardiac MRI summary points R J Keenan CRG 2010 Dr R J Keenan CRG 2007
16 5 learning points CT dose = low and decreasing to < 1mSv CACS = CVD risk stratification - adjuvant CCTA = coronary stenosis imaging - exclude CAD cardiac MRI = function, myocardial, valvular disease ROUTINE! R J Keenan CRG 2010 Dr R J Keenan CRG 2007
17 Cardiac CT Radiation Dose Dr R J Keenan CRG 2007 R J Keenan CRG 2010
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19 Cardiac CT System Siemens Dual Source CT dedicated cardiac CT system dual source (2 XR tubes 1.5 tonne) rotation time = 280msec temporal resolution = 70msec detector = 40mm FLASH scanning, high pitch ~ 3.4 dual energy = kvp Dr R J Keenan CRG 2007
20 NY Times article June 2008 the radiation dose from cardiac CTA is several fold higher than nuclear scans or cardiac catheterisation and this dose is correlated with a 2% lifetime risk attributable cancer risk Journalists: Alex Berenson & Reed R J Keenan CRG 2009 Abelson Dr R J Keenan CRG 2007
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23 Cardiac CT Dose ALARA As Low As Reasonably Achievable huge CT advances dose savings since 2006 aggressive dose reduction CCTA dose highly acceptable in 2012 referral pattern change, patient age? next generation = CT dose ~ Xray R J Keenan CRG 2012 Dr R J Keenan CRG 2007
24 CCTA - Radiation dose Dose metrics 1. CTDIvol (CT Dose Index, mgy) - estimates the average radiation dose in all 3 directions (x,y,z) 2. DLP (Dose Length Product) - reflects the total energy absorbed by the patient - recorded from CT scanner 3. Effective Dose (Doseeff, msv) - weighted sum of dose applied to all organs in a CT examination - weighting factors for biological sensitivities of different organs (chest ~ 0.017) - best classifies risk of biological injury R J Keenan CRG 2012 Dr R J Keenan CRG 2007
25 CCTA Radiation Dose Technique Effective Dose pa SPECT Thallium stress 25mSv SPECT Sestamibi stress 12-18mSv CT chest ungated helical 5-7mSv Retrospective mode CCTA 14 msv, (4.5-19) < 5-6mSv Prospective mode CCTA 5 msv,( ) < 3-4mSv FLASH mode CCTA </= 1mSv Diagnostic catheter angiogram 3-6 msv, (3-30) CXR (PA/Lat) Annual background radiation Additional background radiation at altitude USA East-West round trip flight 0.05 msv 2-5mSv (~ 3mSv) + 1.5mSv mSv R J Keenan CRG 2009 Reference: Stolzmann P et al. Eur Radiol 2008; 18: Dr R J Keenan CRG 2007
26 Protection 1 Trial: - prospective trial CCTA radiation dose - multicenter, multivendor observational trial - mean dose ~ 12mSv - marked multicenter variability - up to 6x dose variation JAMA February 2009 R J Keenan CRG 2009 Dr R J Keenan CRG 2007
27 Protection 1 Trial: - independent modifiable CCTA factors to maintain IQ - prospective gating technique (- 78%) - low kvp technique ( 80/100kVp) (- 46%) - dose modulation (pulsing) (- 25%) - non sinus rhythm (+10%) - patient weight (+ 5%) - experience/exam numbers (~ 0%) JAMA February 2009 R J Keenan CRG 2009 Dr R J Keenan CRG 2007
28 CCTA Radiation Dose Technique Mean DLP Dose Length Product Mean Dose (msv) Patient Number Retrospective gated mSv 74 (4.5-19) Prospective gated 290 5mSv 90 ( ) Reference: Heart Vision Audit 2009: Tiffen sample June 2008 May 2009 R J Keenan CRG 2009 Dr R J Keenan CRG 2007 R J Keenan CRG 200
29 CT Dose Reduction CARE Dose 4D UFC Hand CARE Pediatric 80 kv Protocols DSCT Adaptive ECG-Pulsing /Sequence Adaptive Dose Shield Flash Spiral Selective Photon Shield 4D Noise Reduction X-CARE IRIS Reference: Siemens AG Erlangen Germany:
30 CCTA Radiation Dose Dose 35.0 CT 2007 Retrospective Spiral CT upgrade 2009 Prospective Adaptive Sequence Retrospective min dose 4% CT upgrade 2012 Prospective min dose Adaptive Sequence FLASH Cardio mode IR - SAFIRE
31 CCTA Radiation Dose Technique Mean Dose (msv) Retrospective gated < 6mSv Prospective gated 0.8-4mSv Siemens FLASH mode CACS << 2mSv < 0.5mSv Reference: Heart Vision Audit 2011: R J Keenan CRG 2012 Dr R J Keenan CRG 2007 R J Keenan CRG 200
32 Iterative Reconstruction (IR) IR new technique ~ 2011 IR installed on new systems computing power dose reduction 30-60% IQ changes = compromise Siemens IRIS-SAFIRE GE ASIR Philips idose Toshiba AIDR future advances = GE Veo
33 Generation 1 CT Reconstruction Filtered back projection (FBP) Generation 2 Image filters & kernels Generation 3 Image domain algorithm, statistical IR loop Generation 4 Raw data domain algorithm, data reprojection IR loop future GE Veo system - ultralow dose?? CT = XR dose
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35 CACS Coronary Artery Calcium Scoring Dr R J Keenan CRG 2007 R J Keenan CRG 2010
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37 CACS CT scan - ECG gated prospective low dose (< 0.5mSv) CVD risk stratification tool (Agatston 1990) CACS quantifies calcified plaque CACS scores plaques with peak density >130HU Total CACS score ranked against population standards MESA = Multiethnic Study in Atheroslerosis R J Keenan CRG 2012 Dr R J Keenan CRG 2007
38 CAD Risk Stratification: definitions Low risk < 10% /10 year risk cardiac event CCTA Framingham CAD Risk Profile Intermediate risk ~10-20% /10 year risk cardiac event CCTA High risk MISSES (?10-25%) > 20% /10 year risk cardiac event DSA R J Keenan CRG 2009
39 CVD Risk Stratification Event Free Survival 1.7% Normal 2.7% 1V NOD 4.6% 2V NOD 6.9% 3V NOD 7.1% 1V OD 11.3% 2V OD CACS CCTA 20% 3V OD NOD = non obstructive disease OD = obstructive disease Follow-up
40 CACS References High calcium scores in patients with low Framingham risk of CVS disease: implications for more accurate CVS risk assessment in NZ. NZMJ (2011): 124; 1335 The detection of any coronary calcium outperforms Framingham risk score as a first step n screening for coronary atherosclerosis. AJR (2010) 194; Relationship between baseline coronary calcium score and demonstration of coronary stenoses during follow-up: MESA J Am Coll Cardiol (2009) 2; Coronary artery calcium score and risk classification for coronary heart disease prediction. JAMA (2010) 303:16; MESA CACS calculator online R J Keenan CRG 2012 Dr R J Keenan CRG 2007
41 CACS Non-contrast CACS Contrast CCTA R J Keenan CRG 2010
42 Dr R J Keenan CRG 2012
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44 57yr Chinese female CACS - Case 1 strong family history premature CVD cholesterol HDL severe hypertension? HDL functionality R J Keenan CRG 2012 Dr R J Keenan CRG 2007
45 CACS R J Keenan CRG 2012 Dr R J Keenan CRG 2007
46 CACS Total CACS = 0 R J Keenan CRG 2012 Dr R J Keenan CRG 2007
47 CACS R J Keenan CRG 2012 Dr R J Keenan CRG 2007
48 CACS - Case 2 72yr white female, ex smoker familial dyslipidemia moderate family history premature CVD cholesterol, HDL statin intolerant? significant plaque burden R J Keenan CRG 2012 Dr R J Keenan CRG 2007
49 CACS R J Keenan CRG 2012 Dr R J Keenan CRG 2007
50 CACS Total CACS = 81 R J Keenan CRG 2012 Dr R J Keenan CRG 2007
51 CACS R J Keenan CRG 2012 Dr R J Keenan CRG 2007
52 CACS - Interpretation CACS Score (Agatston) Plaque burden Obstructive CAD Risk CVD Risk Guidelines 0 none < 5% very low reassuring 1-10 minimal < 10% low discuss 1 0 prevention mild mild stenoses moderate 1 0 risk modification moderate NOCAD highly likely moderately high > 400 severe > 90% risk of OCAD >/= 1 stenosis high risk modification aspirin consider stress test aggressive risk modification aspirin stress test Reference: Rumberger 1999 R J Keenan CRG 2012
53 CACS result = ranked Agatston score calcification = biomarker of CAD burden CVD risk assessment in low-medium risk patients score = CVD risk extensive evidence base routinely incorporated in CCTA studies (2012) R J Keenan CRG 2012 Dr R J Keenan CRG 2007
54 CACS not included in 2009 NZ CVS Risk Guidelines independent CVD risk cf Framingham risk (Shaw 2003, n = 10,000) 10-25% Framingham low risk CACS high risk (NZMJ 2011) identifies a group with falsely low Framingham CVD risk -ve test = 96% NPV for significant CAD CACS > 1000 = 20% 1yr probability severe/fatal CVD event CACS > 75 th centile, odds ratio 21.5 of MI or CVD (Raggi 2000) good CACS v cath correlation > 6800 pts = 174 caths (MESA 2009) R J Keenan CRG 2012
55 CACS - Selection asymptomatic intermediate risk where clinical decision making difficult ethnic groups Indian, Maori, Pacific Islanders risk understaged FHx premature stroke or CAD - IHD dyslipidaemias for HDL functionality metabolic syndrome R J Keenan CRG 2010
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57 CCTA Coronary CT Angiography Dr R J Keenan CRG 2007 R J Keenan CRG 2010
58 Dr R J Keenan CRG 2010 CCTA
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60 CCTA - Techniques Retrospective Gating original technique higher dose Prospective Gating newer ~ move and shoot low radiation dose FLASH Scan Siemens DSCT, 1 diastolic RR ~ 400msec ultralow dose <1mSv R J Keenan CRG 2009 Dr R J Keenan CRG 2007
61 CCTA Technique sinus rhythm, heart rate control critical +/- β blocker (Metoprolol) mg po routinely pre scan CACS scan during acquisition range planning sublingual GTN spray 2-3 minutes pre scan iv right antecubital, Iopamiro 60ml 6ml/sec + saline flush R J Keenan CRG 2012
62 Dr R J Keenan CRG 2012 ECG Pulsing
63 CCTA - Technique β blockade Technique Total β blocker Prospective gated 54% Retrospective gated DSCT 43% Total (n= 142) 49% Reference: Heart Vision Audit 2009: 1 year sample June May 2009 Amanda Peacock R J Keenan CRG 2009 Dr R J Keenan CRG 2007
64 Coronary Analysis Software
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66 CCTA - Reporting Triage Stenosis Grade: normal minimal < 25% mild 25-49% borderline ~ 50% significant stenosis > 50% moderate 50-69% severe >/= 70% severe stenosis > 70% occlusion ~ 100% R J Keenan CRG 2009 Dr R J Keenan CRG 2007
67 Major CCTA - Indications 1 Chest pain low/intermediate pretest probability CAD Chest pain - uninterpretable or equivocal ETT/imaging Evaluation acute CP (ED) intermediate risk CAD/normal ECG-enzymes Pre-op exclusion CAD prior to valve-aneurysm surgery Suspected coronary anomalies CHF or DCM on echo - new onset for exclusion CAD Reference: CSANZ November 2010 R J Keenan CRG 2012
68 CCTA - Sample Requests Request 1: yr male FHx - premature CAD risk factors = LDL, CRP chest tightness asymptomatic equivocal ETT (ex ECG) Request 2: 55-75yr female FHx - nil significant risk factors = hypertensive SOBOE? false +ve asymptomatic ETT (ex ECG mild ST changes) R J Keenan CRG 2012
69 CCTA M55yr. Atypical CP. Severe Framingham risk factors. PETT. R J Keenan CRG 2009
70 CCTA LAD > 90% M36yr Atypical CP. No Framingham risk factors. NETT.
71 CCTA FPH6911: M56yr ICU. Ex-smoker. Assess suitability as cardiac donor. R J Keenan CRG 2010
72 CCTA LAD 50-60% LAD 50-60% DNC3450: M68yr CP. BETT. LBBB MR stress test -ve Rx medical R J Keenan CRG 2012
73 CCTA LAD >70% LAD >70% LPG8917: M74yr Previous MVR. CT. BETT catheter + PCI R J Keenan CRG 2012
74 CCTA LAD >70% LAD >70% AYD4723: M62yr CT. BETT. AF. FHx IHD catheter R J Keenan CRG 2012
75 CCTA v Catheter - Concordance Christchurch Experience Cath CCTA Christchurch Hospital Validation Study ? false negative catheter (n = 3) Heart Vision Audit (1) Heart Vision Audit (2) TOTAL R J Keenan CRG 2012
76 CCTA Audits Analysis: CCTA v catheter concordance - analysis by vessels technical - analysis by patient patient management Stenosis threshold for analysis - significant (obstructive) CAD > 50% - severe CAD > 70% R J Keenan CRG 2009 Dr R J Keenan CRG 2007
77 2007 Christchurch Hospital validation study CCTA Validation 1 low-intermediate risk pt group, n= 112, av. 60 (+/- 11yr), 64% male iv β blocker HR > 65 radiology - GE 64slice MDCT system, cardiac radiologist reporting cardiology - diagnostic cardiac catheter, cardiologist reporting all reporters blinded to CCTA/catheter results R J Keenan CRG 2012
78 CCTA Validation 2 Patient analysis n = 112 CCTA v catheter sens spec PPV NPV > 50% stenosis - significant CAD 95% 99.7% 91% 99.4% > 75% stenosis - severe CAD 55% 99.4% 75% 98.6% >75% stenosis (calcium adjusted) 69% 85% Reference: CHC Hospital validation study: 2007 R J Keenan CRG 2009
79 HV Audit (1) CCTA Triage Cardiac catheter n=61 (12%) PCI n=36 (7%) CCTA low-medium risk (n=518) CABG n=4 (1%) Medical Reference: Heart Vision Audit 1, Feb Jan 2009 (n = 518) Amanda Peacock extended population R J Keenan CRG 2009 R J Keenan CRG 200
80 HV Audit (2) CCTA Triage CCTA (n=1002) CCTA analysis low-medium risk (n=932) Cardiac cath n=82 (9%) CCTA exclusions (n=70) PCI, CABG Reference: Heart Vision Audit 2, Paula England June 2008 August 2011 (n = 1002) R J Keenan CRG 2012
81 HV Audit (2) Revascularisation FP n = 10 (31%) CCTA analysed n = 932 Moderate-severe CAD n = 447 (48%) Non-significant CAD n = 485 (52%) Reference: CCTA v catheter analysis, HV Audit 2, Paula England June 2008 August 2011 (n = 1002) Catheter n = 82 (18%) No revascularisation n = 49 (58%) PCI n = 32 (39%) CABG n= 1 (1%) R J Keenan CRG 2012 R J Keenan CRG 200
82 HV Audit (2) CCTA reported findings Mild CAD (21%) CCTA low-medium risk (n=932) CAD (69%) CCTA normal (31%) Significant CAD (20%) Severe CAD (6%) Reference: CCTA report analysis, HV Audit 2, Paula England June 2008 August 2011 (n = 1002) R J Keenan CRG 2012 R J Keenan CRG 200
83 CCTA v Catheter Concordance - Audit (2)
84 CCTA v Catheter Concordance - Audit (2)
85 CCTA v Catheter Concordance - Audit (2) **discordant stenosis grade missed lesion
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87 CCTA v Cath Patient discordance > 70% CTA False Negative for Severe CAD HV Audit 2 discordance per patient at >/= 70% stenosis (severe disease) CCTA false negative for severe CAD, n = 5 patients CUX7738, CCTA LAD severe Ca 2+ ~ stenosis 50% cath recommended cath 70% RCA lesion PCI MPJ0813, CCTA mild RCA/moderate LAD stenosis cath 18/12 later RCA severe PCI FPV9509, CCTA moderate LAD/Cx stenoses cath upgraded severe lesions PCI IEH026Z, CCTA moderate >50% LAD stenosis cath upgraded severe lesion PCI FXQ6916, CCTA x1 mild/x2 moderate stenoses cath upgraded to severe lesions PCI SUMMARY: No patient missed, several lesions upgraded R J Keenan CRG 2012
88 CCTA - Clinical Decision making Christchurch Experience CCTA normal/mild disease stop CCTA multivessel/moderate disease Stress Test (MRI) CCTA severe Cardiac catheter planned revascularisation (stent v CABG) R J Keenan CRG 2012
89 Negative CCTA - Prognosis negative CCTA = absent or non-significant CAD long term data accumulating - follow-up > 5 years available consistent results negative CCTA NPV % (< 5yrs) negative CCTA confidently rules out significant CAD negative non-obstructive CCTA predicts very low rate of major CVD events over the longer term (5yrs) R J Keenan CRG 2010 Dr R J Keenan CRG 2007
90 Cardiac Catheter long term data cardiac catheter normality rate ~ 30% cardiac catheter complication rate diagnostic 1.5%, therapeutic 9% stroke 0.4% cardiac catheter false negative rate? 2.5% Christchurch Hospital validation study R J Keenan CRG 2010 Dr R J Keenan CRG 2007
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92 Negative CCTA Non steno-occlusive causes for ischemia coronary anomalies (interarterial) coronary AV fistula coronary aneurysm hypertrophic cardiomyopathy pericardial disease chest disease - PE, bronchiectasis, lung malignancy R J Keenan CRG 2012 Dr R J Keenan CRG 2007
93 Figure 1 Figure 2 Figure 3 Case 4: Syncope. History: 53yr old male with CP, near-syncope on exercise ECG with ST changes. Dr R J Keenan CRG 2012
94 Figure 1 Figure 2 Figure 3 Case 5: Syncope. History: 53yr old male with chest pain, near-syncope on exercise ECG with ST changes. Dr R J Keenan CRG 2012
95 Figure 4 Figure 5 Dr R J Keenan CRG 2012
96 CMRI Cardiac MRI Dr R J Keenan CRG 2007 R J Keenan CRG 2010
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98 Figure 1 (Fiesta) Figure 2 (MDE) Case 1: Recurrent stroke History: 74yr old male, recurrent CVA, echo LV dilatation and apical akinesis with normal carotid Doppler. Dr R J Keenan CRG 2012
99 Figure 3 (Fiesta) Figure 4 (MDE) Dr R J Keenan CRG 2012
100 Figure 1 (Fiesta) Figure 2 (MDE) Case 2: Exercise induced syncope. History: 6yr old female with exercise induced chest pain. Dr R J Keenan CRG 2012
101 Figure 3 (Fiesta) Figure 4 (T2 DIR) Dr R J Keenan CRG 2012
102 Figure 4 Figure 5 Dr R J Keenan CRG 2012
103 Figure 1 Figure 2 Figure 3 Case 3: Breathlessness and abnormal CXR. History: 38yr female with RV dilated on echocardiography. Dr R J Keenan CRG 2012
104 RA LA Figure 4 Figure 5 Aorta red, MPA blue LV SV = 108cc RV SV = 143cc Qp:Qs = 1.8 : 1.0 Dr R J Keenan CRG 2012
105 Siemens Siretom dedicated CT Head scanner 1975
106 5 learning points CT dose = low and decreasing to sub 1mSv CACS = CVD risk stratification adjuvant CCTA = coronary stenosis imaging cardiac MRI = LV function, myocardial, valvular disease ROUTINE! R J Keenan CRG 2012 Dr R J Keenan CRG 2007
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