CT Perfusion. U. Joseph Schoepf, MD, FAHA, FSCBT MR, FSCCT Professor of Radiology, Medicine, and Pediatrics Director of Cardiovascular Imaging

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1 CT Perfusion U. Joseph Schoepf, MD, FAHA, FSCBT MR, FSCCT Professor of Radiology, Medicine, and Pediatrics Director of Cardiovascular Imaging

2 Disclosures Consultant for / research support from Bayer Bracco General Electric Medrad Siemens

3 Integrative CHD Imaging with CT Primary morphological vs. functional evaluation of CAD (i.e. SPECT vs. ICA, CTA)? Early attempts at CT imaging Limited by experimental nature Limited by dedicated acquisition protocols Hybrid Imaging (e.g. SPECT and CT) Dual energy CT for myocardial perfusion defects Delayed enhancement dual energy CT Adenosine stress dual energy CT Quantitative, time resolved perfusion assessment

4 140kV 80 / 100kV Integrative Imaging: DECT

5 DECT for Myocardial Ischemia 74 yo woman with chest pain and abnormal SPECT 2x64x0.6mm, 80kV/140kV 0.33 s rotation time

6 Morphology and Function: DECT 74 yo woman with chest pain and abnormal SPECT Tight proximal stenosis D1 B. Ruzsics et al., Circulation 2008

7 Morphology and Function: DECT 74 yo woman with chest pain and abnormal SPECT B. Ruzsics et al., Circulation 2008

8 DECT Postprocessing F. Schwarz et al., Eur J Radiol 2008

9 DECT Radiation Dose 16 Slice CT DSCT DECT 12 ± 3.59 msv 9.8 ± 4.77 msv 4.54 ± 1.87 msv JM Kerl et al., Eur Radiol 2010

10

11 DE ccta LAD 36 yo woman, DM I ho LAD infarct SPECT DECT

12 61 yo man, atypical chest pain Reversible Ischemia at Rest DECT

13 Vliegenthart et al., AJR in press DECT Can Detect Subtle Pathology

14 Delayed Enhancement DECT B. Ruzsics et al., HEART 2009

15 First Pass LAD Delayed B. Ruzsics et al., HEART, in press ccta Delayed Enhancement DECT

16 Ruszsics et al., RSNA 2009 Delayed Enhancement DECT

17 1 month 0 1 week Abnormal SPECT rest and/or stress Rest DECT Adenosine DECT Rest cemri (perfusion) Adenosine cemri (perfusion) Adenosine protocol: 140 µg/min/kg Delayed DECT (sequential) Delayed Enhancement (viability) B. Ruzsics et al., AHA 2008 Adenosine Stress DECT

18 Adenosine Stress DECT LM LAD D1 Reversible Ischemia

19 Adenosine Stress cmri Reversible Ischemia

20 Rest Stress Delayed Reversible Ischemia

21 Larger scan field of view (SFOV) for Dual Energy modes SFOV A/B detector: 50/33 cm 33 cm Next Generation DECT

22 Dual Energy with Selective Photon Shield Improved separation of low and high energies Noise reduction Greater dose reserve number of quanta S 1 : 80 kv x S 2 : 140 kv + SPS 80 kv 140 kv 140 kv + SPS 0.4 mm Sn photon energy (kev) Next Generation DECT

23 83 msec Temporal Resolution in Dual Energy Mode 165 msec 83 msec DECT Temporal Resolution

24 Next Generation DECT

25 Quantitative DECT Perfusion Rest Stress

26 ECG triggered sequential shuttle mode, coverage 8 cm 4 cm 4 cm Dynamic Time Resolved Perfusion

27 Untitled-2 Radiation dose: 1290±233 mgy*cm 18 msv Stress Dynamic CT Perfusion Protocol G. Bastarrika et al., Invest Radiol 2010

28 140 µg/min/kg Adenosine Stress Dynamic Time Resolved Perfusion G. Bastarrika et al., J Cardiovasc Comput Tomography 2010

29 Absolute MBF Quantification MBF: 124ml/100 ml/min MBF: 60ml/100 ml/min

30 Absolute MBF Quantification 160 Myocardial Blood Flow (ml/100 ml/min) ± ± ± All CT Segment 1 Normal / Ischemic 2 Myocardium Significant difference in MBF between normal and hypoperfused myocardium (p<0.001) Moderate correlation between absolute MBF quantification and upslope of SI over time curves (r = 0.47, p<0.01) Moderate correlation between MBF and semiquantitative upslope for hypoperfused and normal myocardium (r = 0.41, p<0.01 vs. r = 0.43, p<0.01)

31 ccta Perfusion Viability Dynamic Time Resolved Perfusion G. Bastarrika et al., Invest Radiol 2010

32 50yo man w/ chest pain

33 Dynamic Time Resolved Perfusion

34 Discriminator DECT Dynamic Perfusion Radiation dose Volume coverage Temporal resolution Ease of acquisition Ease of post processing Structural information Perfusion information Viability information Quantification

35 Summary Future Perspectives Promising developments for CT imaging of myocardial perfusion and delayed enhancement CT not the primary method for evaluation of myocardial perfusion CTA is mainly aimed at imaging the coronaries CT a possibly attractive modality for integrative imaging of anatomy and perfusion Further refinements in technique (e.g. area detector CT, dual energy CT)

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