Improving Diagnostic Accuracy of MDCT Coronary Angiography in Patients with Mild Heart Rhythm Irregularities Using ECG Editing

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1 Cademartiri et al. Heart Rhythm Irregularities on MDCT Angiography Cardiac Imaging Original Research A C M E D E N T U R I C A L I M A G I N G AJR 2006; 186: X/06/ American Roentgen Ray Society Y O Filippo Cademartiri 1,2 Nico R. Mollet 1,2 Giuseppe Runza 1,3 Timo Baks 1,2 Massimo Midiri 3 Eugene P. McFadden 2 Thomas G. Flohr 4 Bernd Ohnesorge 4 Pim J. de Feyter 1,2 Gabriel P. Krestin 1 F Cademartiri F, Mollet NR, Runza G, et al. Keywords: arteriography, coronary angiography, ECG editing, heart rhythm, MDCT angiography DOI: /AJR Received November 19, 2004; accepted after revision February 7, Department of Radiology, Erasmus Medical Center, Dr. Molewaterplein, 40, Rotterdam 3015GD, The Netherlands. Address correspondence to F. Cademartiri 2 Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands. 3 DIBIMEL, Section of Radiological Sciences, University of Palermo, Palmero, Italy. 4 Computed Tomography, Siemens Medical Solutions, Forchheim, Germany. Improving Diagnostic Accuracy of MDCT Coronary Angiography in Patients with Mild Heart Rhythm Irregularities Using ECG Editing OBJECTIVE. The objective of our study was to compare diagnostic accuracy of MDCT coronary angiography in a population of patients with mild heart rhythm irregularities before and after editing the ECG. SUBJECTS AND METHODS. Thirty-eight patients who underwent MDCT coronary angiography and conventional coronary angiography were enrolled in the study. The inclusion criterion was the presence of mild heart rhythm irregularities (i.e., premature beats; atrial fibrillation; mistriggering; or low heart rate, defined as 40 beats per minute or less) during the scan. All patients underwent MDCT with the following parameters: 16 detectors; collimation, 0.75 mm; gantry rotation time, 375 msec; 120 kv; and effective milliampere-second setting, Images were reconstructed in two settings: before ECG editing and after ECG editing (i.e., arbitrary modification of temporal windows within the cardiac cycle at the site of mild heart rhythm irregularities). Data sets were scored for the presence of significant stenoses ( 50% lumen reduction) in coronary segments 2 mm diameter. The results of the two groups were compared with a McNemar test, and a p value of less than 0.05 was considered significant. RESULTS. The sensitivity, specificity, and negative and positive predictive values of MDCT coronary angiography for the detection of significant stenoses before and after ECG editing were 63% (41/65) and 92% (78/85); 97% (251/260) and 96% (305/317); 87% (62/71) and 87% (81/93); 91% (251/275) and 97% (305/313), respectively (p < 0.05). The proportion of nonassessable segments was reduced from 17% (70/416) before ECG editing to 2% (10/416) after. CONCLUSION. ECG editing significantly improves diagnostic accuracy in a selected population of patients with mild heart rate irregularities. DCT scanners with increased M spatial and temporal resolution were recently introduced [1]. In their early experiences, investigators reported improved results in visualization of the coronary arteries and in the detection of significant coronary artery disease ( 50% lumen reduction) in a selected population of patients [2, 3]. One limitation of MDCT coronary angiography is that high, irregular, or high and irregular heart rates prevent adequate visualization and assessment of the coronary vessels, and for this reason, patients are usually excluded from analysis or scanning [4]. This is because at high heart rates the motion speed of the coronary vessels is increased and the temporal window suited for imaging (e.g., mid- to enddiastole) is shortened. In patients with irregular heart rates, such as premature beats and atrial fibrillation, the temporal variability of the diastolic phase is increased between contiguous heart cycles. This creates motion artifacts due to the inaccurate location of temporal windows, the lack of data, or both. This prevents the application of homogeneous settings for image reconstructions. By arbitrarily modifying the position of the temporal windows within the cardiac cycle, it is possible to correct and compensate for part or all of the artifacts produced by mild heart rhythm irregularities (i.e., ECG editing). The aim of this study was to compare diagnostic accuracy in a population of patients with mild heart rhythm irregularities using two different image reconstruction protocols for MDCT coronary angiography. Subjects and Methods Patient Population Between April 2003 and February 2004, 42 consecutive patients (34 men; mean age, 59 ± 11 [SD] years) with stable angina and scheduled for coronary angiography were prospectively enrolled in the study. 634 AJR:186, March 2006

2 Heart Rhythm Irregularities on MDCT Angiography A B C Fig. 1 Compensation of artifacts from premature beats with MDCT. Example of data set with premature beats before (A C) and after (D F) ECG editing obtained in 59-yearold man. A, ECG before editing shows three premature beats (asterisks) in background heart rate of approximately 45 beats per minute. B and C, Data set resulting from a reconstruction performed without editing shows motion artifacts at level of origin of left coronary artery (arrowheads). D F, After ECG editing, artifacts are ruled out and coronary vessels are assessable. Significant stenosis of proximal left anterior descending artery was missed before ECG editing (B) because of artifacts, but stenosis (arrowheads, E and F) became apparent after ECG editing. D E F AJR:186, March

3 Cademartiri et al. Inclusion criteria for the scan were heart rate (spontaneous or β-blocker-induced) of less than 70 beats per minute (bpm) and the ability to hold a breath for 20 sec. Inclusion criteria for the study were presence of premature beats, atrial fibrillation with low ventricular response, mistriggering of the R wave (i.e., widening of QRS complex, bundle branch block), and low heart rate (i.e., < 40 bpm) (Appendix 1, available online at These criteria are defined as a group as mild heart rhythm irregularities. Exclusion criteria were a high heart rate (> 70 bpm) with bigemini or trigemini premature beats, previous allergic reaction to iodine contrast medium, renal insufficiency (serum creatinine > 120 mmol/l), pregnancy, respiratory impairment, unstable clinical status, marked heart failure, and previous bypass surgery or percutaneous coronary interventions. Patients meeting the inclusion criteria also underwent noninvasive MDCT coronary angiography. The institutional review board approved the study, and the patients gave informed consent. MDCT The heart rate of each patient was measured on arrival. Patients with a prescan heart rate of 65 bpm or greater were given 100 mg of metoprolol orally and the scan was obtained 1 hr later. Patients were positioned on the CT table and connected to the ECG trace. The variation in heart rate was observed for 5 min and was then tested during apnea (20 sec). If at rest and during apnea the variation in heart rates was compatible with the definition of mild heart rhythm irregularities, the patient underwent the scanning procedure. In all patients, a bolus (100 ml at 4 ml/sec) of iodinated contrast material (iomeprol 400 mg I/mL, Iomeron, Bracco) followed by a saline chaser (40 ml at 4 ml/sec) was administered using a doublehead power injector (Stellant, MedRad) through an 18-gauge cannula positioned in an antecubital vein. The scanning parameters for MDCT coronary angiography (Sensation 16, Siemens Medical Solutions) were number of detectors, 16; individual detector width, 0.75 mm; gantry rotation time, 375 msec; effective temporal resolution, 188 msec; 120 kv; effective mas; feed/rotation, 3.0 mm; and scan direction, craniocaudal. Synchronization between the passage of contrast material and data acquisition was achieved with realtime bolus tracking (CARE bolus, Siemens Medical Solutions) using a region of interest in the ascending aorta and a threshold of 100 H above the baseline attenuation to trigger the scan. The heart rate and ECG trace were recorded during scanning [5]. Image Reconstruction Two study data sets were reconstructed using a retrospective ECG-gating technique. The first study data set the standard reconstruction protocol was selected among three reconstructed data sets without any ECG editing using temporal windows starting 350, 400, and 450 msec before the next R wave. Two experienced operators selected in consensus the data set with the fewest motion artifacts. The second study data set the ECG-editing reconstruction protocol was reconstructed in consensus by two experienced operators using ECG editing (available at the MDCT scanner console) at the level of anomalies of the ECG signal due to premature beats (Appendix 1, which is available online at and Fig. 1), atrial fibrillation, mistriggering, and low heart rate. The ECG-editing procedure consisted of an arbitrary modification (i.e., deletion, insertion, or repositioning) of the number and position of temporal windows to provide the reconstruction software with information with the least residual motion. Both data sets were reconstructed with the following parameters: effective slice width, 1 mm; reconstruction interval, 0.5 mm; field of view, 160 mm; and convolution filter, medium smooth (B30f). Image Analysis Two experienced observers (the same who selected the data sets), blinded to the results of the conventional coronary angiography and the identity of patients, assessed in consensus the data set for the presence of significant stenoses ( 50% lumen reduction). The evaluation of the data was performed 3 months after the reconstruction and selection of the data sets, and the observers were unaware whether the data set was edited or unedited. The evaluation was performed following the classification for coronary segments established by the American Heart Association [6]. Significant stenoses were scored as absent (< 50%) or present ( 50%). Significant lesions had an average diameter stenosis of 50% or more measured in two longitudinal views orthogonal to each other. Conventional Coronary Angiography Conventional coronary angiography was performed within 2 weeks of MDCT coronary angiography using a standard technique. One experienced observer, unaware of the results of MDCT coronary angiography, determined the diameter of all coronary branches and evaluated for the presence of significant stenoses using quantitative coronary angiography (CAAS, Pie Medical Imaging). Lesions with an average diameter stenosis of 50% or more in two orthogonal views were considered significant obstructions. Statistical Analysis The result of quantitative coronary angiography performed in two orthogonal projections was used as the reference standard to classify stenoses as significant. The number of assessable segments on MDCT coronary angiography was used to calculate sensitivity, specificity, positive predictive value, and negative predictive value with 95% confidence intervals. A McNemar nonparametric test was used to compare the diagnostic accuracy, and a p value of less than 0.05 was considered significant. Results No significant adverse reactions to contrast material were recorded. Of the 42 patients enrolled in the study, four (10%) did not undergo MDCT coronary angiography because heart rate variations observed while the patient was on the CT table were not compatible with inclusion criteria regarding mild heart rhythm irregularities. Therefore, 38 patients (33 men; mean age, 59 ± 11 years; mean heart rate during the scan, 54 ± 9 [SD] bpm) were suitable for MDCT coronary angiography, image reconstruction, and data analysis. After exclusion of segments with a diameter of less than 2 mm, 416 segments remained available for analysis, 88 of which had a significant stenosis (21% per segment, corresponding to 2.3 lesions per patient). Of the 38 patients with mild heart rhythm irregularities, 21 irregularities were classified as premature beats, four as atrial fibrillation, six as mistriggering, and seven as low heart rate. Sensitivity, specificity, negative predictive value, and positive predictive value for the detection of significant stenoses for the standard and ECG editing protocols were 63% (41/65) and 92% (78/85); 97% (251/260) and 96% (305/317); 87% (62/71) and 87% (81/93); 91% (251/275) and 97% (305/313), respectively (p < 0.05). Discussion Encouraging results have been published regarding the detection of significant stenoses with MDCT coronary angiography in a selected population of patients [2, 3]. High and irregular heart rates are known as limitations of this technique [1]. To date, they are used as exclusion criteria for the studies and are aggressively treated with oral β-blockers [2, 3]. However, for mild heart rate irregularities, there remains room for interaction with the raw data and the ECG trace. The main drawbacks of a high heart rate are the increased speed of the coronary arteries and reduced duration of diastole [7]. With a temporal resolution of approximately 200 msec, this results in a limited possibility to 636 AJR:186, March 2006

4 Heart Rhythm Irregularities on MDCT Angiography adapt the position of the temporal window in the cardiac cycle. This limitation is less compromising at a low heart rate, for which a longer diastolic phase is available. In these conditions, the position of the temporal window in the cardiac cycle can be modified arbitrarily to compensate for motion artifacts resulting from arrhythmias. This tool can be defined as ECG editing. In fact, mild heart rhythm irregularities can be ruled out after careful ECG editing, thereby providing increased diagnostic accuracy (Table 1). In our institution during the period of this study (10 months), we could include 42 additional patients, while the overall population included for MDCT coronary angiography was 398 patients. This finding suggests that ECG techniques could have been used for evaluation of an additional 42 patients (11%). In our study, we compared the reconstruction capabilities of an MDCT scanner in the presence of mild heart rhythm irregularities before and after ECG editing. We TABLE 1: Diagnostic Accuracy of the Standard ECG Protocol Versus the ECG-Editing Protocol found that the sensitivity and negative predictive value for the detection of significant stenoses were significantly different before and after ECG editing. The effect of ECG editing on diagnostic accuracy depends on the number and distribution of lesions throughout the coronary tree. A population with a lower probability of disease (e.g., younger patients or those with less evident symptoms) would show a smaller variation in the negative predictive value than that shown in our study. Segment No. (%) No. (%) Sensitivity Specificity Positive Predictive Negative Predictive AHA Name No. of SDS Protocol NA SDS in NA (95% CI) (95% CI) Value (95% CI) Value (95% CI) 1 Proximal RCA 38 7 (18) Standard ECG 15 (40) 2 (28) 100 (54 100) 88 (63 98) 75 (34 97) 100 (78 100) ECG editing 5 (13) 1 (14) 100 (59 100) 92 (74 99) 78 (39 98) 100 (85 100) 2 Middle RCA (53) Standard ECG 7 (22) 4 (24) 100 (75 100) 83 (51 97) 87 (59 98) 100 (69 100) ECG editing 1 (3) 0 (0) 100 (80 100) 86 (57 98) 90 (66 98) 100 (73 100) 3 Distal RCA 23 6 (26) Standard ECG 3 (13) 2 (33) 100 (39 100) 94 (69 99) 80 (28 99) 100 (78 100) ECG editing 0 (0) 0 (0) 100 (54 100) 94 (71 99) 86 (42 99) 100 (79 100) 4 PDA 14 2 (14) Standard ECG 2 (14) 0 (0) 50 (1 87) 100 (69 100) 100 (2 100) 91 (58 99) ECG editing 0 (0) 0 (0) 50 (1 87) 100 (73 100) 100 (2 100) 92 (63 99) 5 Left main artery 38 0 (0) Standard ECG 10 (26) 0 (0) NA 100 (87 100) NA 100 (87 100) ECG editing 1 (3) 0 (0) NA 100 (90 100) NA 100 (90 100) 6 Proximal LAD (40) Standard ECG 15 (40) 6 (40) 78 (39 98) 93 (66 99) 88 (47 99) 87 (59 98) ECG editing 3 (8) 1 (7) 86 (57 98) 91 (69 98) 86 (57 98) 91 (69 98) 7 Middle LAD (40) Standard ECG 12 (34) 5 (36) 100 (63 100) 100 (78 100) 100 (63 100) 100 (78 100) ECG editing 2 (6) 2 (14) 100 (73 100) 100 (83 100) 100 (73 100) 100 (83 100) 8 Distal LAD 32 3 (9) Standard ECG 5 (16) 0 (0) 100 (29 100) 96 (78 99) 75 (19 99) 100 (85 100) ECG editing 0 (0) 0 (0) 100 (29 100) 97 (82 99) 75 (19 99) 100 (87 100) 9 First diagonal artery 28 1 (4) Standard ECG 4 (14) 0 (0) 100 (2 100) 96 (78 99) 50 (1 99) 100 (84 100) ECG editing 0 (0) 0 (0) 100 (2 100) 93 (75 99) 33 (0 95) 100 (86 100) 10 Second diagonal artery 16 0 (0) Standard ECG 1 (6) 0 (0) NA 100 (78 100) NA 100 (78 100) ECG editing 1 (6) 0 (0) NA 100 (78 100) NA 100 (78 100) 11 Proximal CX artery 37 7 (19) Standard ECG 6 (16) 0 (0) 100 (47 100) 100 (86 100) 100 (47 100) 100 (86 100) ECG editing 1 (3) 0 (0) 86 (42 96) 100 (88 100) 100 (54 100) 97 (82 99) 12 First marginal artery (30) Standard ECG 7 (21) 2 (20) 100 (63 100) 100 (81 100) 100 (63 100) 100 (81 100) ECG editing 0 (0) 0 (0) 100 (69 100) 96 (78 99) 91 (58 99) 100 (84 100) 13 Middle CX artery 30 5 (17) Standard ECG 3 (10) 0 (0) 100 (47 100) 96 (77 99) 83 (35 99) 100 (83 100) ECG editing 0 (0) 0 (0) 100 (47 100) 96 (79 99) 83 (35 99) 100 (85 100) 14 Second marginal artery 15 0 (0) Standard ECG 1 (20) 0 (0) NA 100 (76 100) NA 100 (76 100) ECG editing 0 (0) 0 (0) NA 100 (78 100) NA 100 (78 100) 15 Posterolateral branch 7 1 (14) Standard ECG 0 (0) 0 (0) 100 (2 100) 100 (54 100) 100 (2 100) 100 (54 100) ECG editing 0 (0) 0 (0) 100 (2 100) 100 (54 100) 100 (2 100) 100 (54 100) All a (21) Standard ECG 70 (17) 0 (0) 63 (52 57) 97 (93 98) 87 (77 97) 91 (87 94) ECG editing 10 (2) 0 (0) 92 (83 97) 96 (93 98) 87 (78 94) 97 (95 98) Note AHA = American Heart Association segmental classification [6], SDS = significantly diseased segments (> 50% lumen reduction at quantitative coronary angiography), NA = not assessable, CI = confidence interval, RCA = right coronary artery, PDA = posterior descending artery, LAD = left anterior descending, CX = circumflex. a Calculation performed including the significantly diseased segments as false-negatives. AJR:186, March

5 Cademartiri et al. Our results suggest that from the technical point of view heart rhythm irregularities are not an absolute limitation of the technique. In fact, our technique exploits the flexibility of retrospective reconstruction to the limit. Another observation is that the number of assessable segments is increased after ECG editing. The motion speed of the coronary vessels, especially if compared with effective temporal resolution of MDCT, remains a limitation. To compensate for this limitation, a slow heart rate, faster rotation time, or both are required. Patients with heart rates above 70 bpm were not enrolled to prevent image degradation from other sources than those targeted by our study. Only cases that we defined as mild heart rhythm irregularities could be included in the evaluation because of the still limited effective temporal resolution of MDCT coronary angiography. Scanning of patients with mild heart rhythm irregularities does not allow the use of X-ray reduction software such as ECG pulsing [8]. This is because the algorithm for dose reduction works with prospective triggering based on the R wave. In the presence of heart rate abnormalities, the location of the low-dose period will be variable and can fall within the diastole. Therefore, the presence of mild heart rhythm irregularities prevents the application of dose reduction protocols that are based on prospective tube current modulation. In addition, the presence of heart rhythm irregularities, with the exclusion of low heart FOR YOUR INFORMATION rates, does not allow the application of multisegmental reconstruction algorithms [9, 10]. This is because the variable diastolic filling of the heart prevents proper interpolation between the data originating from neighboring heart cycles. Another disadvantage is related to the additional time required to edit the ECG. That time in our study was, on average, 7 min. Editing the ECG in MDCT coronary angiography reduces the negative impact of mild heart rhythm irregularities on the diagnostic accuracy in a selected population of patients with stable angina. Improvements in scanner technology (e.g., faster rotation time or increased temporal resolution) and software capabilities (e.g., automatic recognition and editing of heart rhythm irregularities) could allow patients with mild arrhythmias to be scanned routinely with good diagnostic accuracy. References 1. Flohr TG, Schoepf UJ, Kuettner A, et al. Advances in cardiac imaging with 16-section CT systems. Acad Radiol 2003; 10: Nieman K, Cademartiri F, Lemos PA, Raaijmakers R, Pattynama PM, de Feyter PJ. Reliable noninvasive coronary angiography with fast submillimeter multislice spiral computed tomography. Circulation 2002; 106: Ropers D, Baum U, Pohle K, et al. Detection of coronary artery stenoses with thin-slice multi-detector row spiral computed tomography and multiplanar reconstruction. Circulation 2003; 107: Nieman K, Rensing BJ, van Geuns RJ, et al. Noninvasive coronary angiography with multislice spiral computed tomography: impact of heart rate. Heart 2002; 88: Cademartiri F, Nieman K, van der Lugt A, et al. Intravenous contrast material administration at 16-detector row helical CT coronary angiography: test bolus versus bolus-tracking technique. Radiology 2004; 233: Austen WG, Edwards JE, Frye RL, et al. A reporting system on patients evaluated for coronary artery disease. Report of the Ad Hoc Committee for Grading of Coronary Artery Disease, Council on Cardiovascular Surgery, American Heart Association. Circulation 1975; 51[suppl 4]: Achenbach S, Ropers D, Holle J, Muschiol G, Daniel WG, Moshage W. In-plane coronary arterial motion velocity: measurement with electron-beam CT. Radiology 2000; 216: Jakobs TF, Becker CR, Ohnesorge B, et al. Multislice helical CT of the heart with retrospective ECG gating: reduction of radiation exposure by ECGcontrolled tube current modulation. Eur Radiol 2002; 12: Dewey M, Laule M, Krug L, et al. Multisegment and halfscan reconstruction of 16-slice computed tomography for detection of coronary artery stenoses. Invest Radiol 2004; 39: Halliburton SS, Stillman AE, Flohr T, et al. Do segmented reconstruction algorithms for cardiac multislice computed tomography improve image quality? Herz 2003; 28:20 31 A data supplement for this article can be viewed in the online version of the article at: AJR:186, March 2006

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