New Technologies for Cardiac CT. Geoffrey D. Rubin, MD, MBA, FACR, FNASCI Duke University

Transcription

1 1996 New Technologies for Cardiac CT Geoffrey D. Rubin, MD, MBA, FACR, FNASCI Duke University

2 New Technology The Long View Levels of Efficacy Endpoint Examples 1: Technical Imaging resolution 2: Diagnostic Accuracy Sensitivity/specificity 3: Diagnostic Thinking Pre- and post-test changes in subjectively determined outcome 4: Therapeutic Effects on choice of therapy 5: Patient Outcome Impact of test information on morbidity, mortality, and QALYs 6: Societal Cost-benefit/effectiveness for society Frybach & Thornbury. Med Decis Making 1991;11:88-94

3 Reporting Templates Cardiac CT CT Scanner Contrast Injector Advanced Visualization and Analysis Software

4 Reporting Templates Evidence Base Cardiac CT CT Scanner Contrast Injector Evidence Base Advanced Visualization and Analysis Software

5 So What s New in 2015? Acquisition Technologies Advanced Visualization/Analysis Evolution of Dual Source FFRCT Wide Area Detector CT Perfusion Maps Multi-layer detector for spectral Evidence Base CT ED Clinical Trials Contrast dose and delivery Stable chest pain trials Iterative Reconstruction FFRCT Trials

6 So What s New in 2015? Acquisition Technologies Advanced Visualization/Analysis Evolution of Dual Source FFRCT Wide Area Detector CT Perfusion Maps Multi-layer detector for spectral Evidence Base CT ED Clinical Trials Contrast dose and delivery Stable chest pain trials Iterative Reconstruction FFRCT Trials

7 So What s New in 2015? 3D Printing Information Technology Visualization ACRSelect decision support Planning Graft creation PACS, RIS, reporting system, EMR integration Image Sharing Transcatheter Valve Prostheses Aortic Mitral Univ College Dublin

8 Contrast Delivery Management System Centralized server PACS/RIS integration Protocol management Recording and archive of injection parameters Performance metrics for resource utilization, operations, safety

9 Dual-energy (spectral) CT Technologies Applications Dual source Contrast medium dose reduction Fast kv switching Metal artifact reduction Dual layer detector Material decomposition Serial single-energy scans Calcium iodine separation 4D Cardiac most challenging, but gains are being made

10 Dual-energy (spectral) CT Carrascosa et al, Eur J Radiol 2015

11 Dual-energy (spectral) CT Virtual Unenhanced True Unenhanced Virtual 50 kev Pinho et al, Eur Radiol 2013; 23:351

12 Dual-energy (spectral) CT Rodriguez-Granillo et al, Card Diagn Ther 2015; 5:79

13 Coronary CTA Evidence Base Acute Coronary Syndrome ROMICAT II high risk plaque predicts ACS independent of % stenosis Puchner et al, JACC 2014; 64:684 Chest pain in outpatients PROMISE SCOT-HEART PLATFORM

14 10,003 patients with new onset chest pain (not ACS) randomized to standard functional testing or CCTA Pragmatic trial design 64-row CT scanners CTA Functional CTA Strategy Strategy Strategy Nuclear CTA Stress 93.8% 67.5% 0.9% Stress Echo2.9% 22.4% 93.7% Patients followed for median of 2.0 (range ) yrs. Exercise No Test ECG3.1% 10.2%% 4.9%

15 PROMISE Outcomes Primary Composite End Point Death (any cause) MI Hospitalized for unstable angina Major procedural complications

16 PROMISE Outcomes CT Strategy (N=4996) Functional-Testing Strategy (N=5007) P Value Primary Composite End Point 3.3% 3.0% 0.75 Cardiac Catheterization 12.2% 8.1% Catheterization showing no obstructive CAD 3.4% 4.3% 0.02 Revascularization 6.2% 3.2% <0.001

17 SCOT-HEART David Newby, PI Lancet 2015; 385: ,146 patients with chest pain randomized to standard care or standard care + CCTA Pragmatic trial design 64-row or 320-row CT scanners Patients followed for median of 1.7 (range ) years

18 SCOT HEART: Invasive Procedures Median 1.7 Years of Follow-up Coronary Angiography Coronary Revascularisation 25 HR 1.06 [ ], P=0.451 HR 1.20 [ ], P=0.061 Proportion of patients with an event (%) 20 CTCA Standard Care Proportion of patients with an event (%) Cumulative incidence, % 5 15% 10% 5% CTCA Standard Care strata AllocatedTreatment=2 AllocatedTreatment=1 CTCA Standard Care CTCA Standard Care 0 0% Time, days Follow Up Follow Up (years) (years)

19 SCOT Heart: Clinical Outcomes Median 1.7 Years of Follow-up CHD Death & Non-Fatal MI CHD Death, Non-Fatal MI & Stroke 5 5% HR 0.62 [ ], P= % HR 0.64 [ ], P=0.056 Proportion of patients with an event (%) Cumulative incidence, % 4% 3% 2% 1% Standard Care CTCA strata AllocatedTreatment=2 AllocatedTreatment=1 Proportion of patients with an event (%) Cumulative incidence, % 4% 3% 2% 1% Standard Care CTCA strata AllocatedTre AllocatedTre 0 CTCA Standard Care 0% Time, days 0 CTCA Standard Care 0% Time, days Follow Up (years) Follow Up (years)

20 SCOT Heart: Conclusions Regarding CCTA Increases dx of CHD Does not affect short-term anginal symptoms May increase coronary revascularization (9.7 vs 11.2%, 1.5% increase) May reduce MI (1.3 vs 2.0%, 0.7% reduction)

21 398,978 pts w/ suspected CAD to Cath (663 U.S. hospitals over 4 years) 37.6% had obstructive CAD 39.2% were normal N Engl J Med 2010;362:886-95

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23 Non-Obst. CAD Obstructive CAD No ICA PLATFORM Trial Eur Heart J NI Test Planned ICA Planned Usual Care FFRCT Usual Care FFRCT 100% 100% Key Results 90% 90% FFRCT vs. U.C. 27% 80% 80% No No cath in 61% 70% 70% 73% events 60% 60% at 90 Same % (+) caths 50% 50% days 40% 40% 6x less (-) caths 30% 30% 27% 20% 12% 18% 20% No sig increase in 10% 10% 12% downstream cath 0% 0% n=100 n=104 n=187 n=193 P = 0.95 P <

24 Summary Cardiac CT Technology Think Long Think Broad Think Value patient imager

25 Technology I Want to be Discussing Heart rate independent cardiac motion-free acquisition Automated optimized protocol definition based on CT measured biometrics (wt, body contour/composition, HR, ) Comprehensive preprocessing with integrated volume rendering, MPR, & annotated quantization of stenosis and plaque character. Automated prior exam analysis for assessment of all non-normal findings Comprehensive intuitive data display with pre-population of reporting template