U. Joseph Schoepf, MD Prof. (h.c.), FAHA, FSCBT-MR, FNASCI, FSCCT Professor of Radiology, Medicine, and Pediatrics Director, Division of Cardiovascular Imaging MEDICAL UNIVERSITY of SOUTH CAROLINA
Disclosures Consultant for / research support from Astellas Bayer Bracco GE Healthcare Guerbet Medrad Siemens Healthcare Cinematic Rendering not for clinical use
Technology Evidence Closing the Gap
Iterative Image Reconstruction Improved signal / noise ratio Lower radiation dose (e.g. pediatric CT) Improved image quality (e.g. obese patients) Decreased artifacts (e.g. stents, implanted devices) G Bastarrika et al., Radiology 2009 LL Geyer et al., Radiology 2015
M. Renker et al., Radiology 2011 Reduced Calcium Blooming Artifacts FBP Iterative Recon
Improved Specificity for Stenosis n = 55 Patients with Agatston Score >400 M. Renker et al., Radiology 2011
Low kv Scanning in Adults 45 years, male Chest pain HR: 64 BPM 70kV 0.21mSV Meyer, Haubenreisser, Schoepf, Henzler et al., Radiology 2014
Routine ccta at < 0.5 msv is a Reality Meyer, Haubenreisser, Schoepf, Henzler et al., Radiology 2014
Low kv Scanning for Everybody! BMI: 39.6 kg/m 2 80kV 49 ml CM 26 DLP ~0.4 msv
Radiation from Heart CT and Other Imaging Tests C.N. De Cecco, Schoepf UJ et al., Circulation, 2014
Gentle Techniques TAVR Workup with <40cc Contrast BMI: 39 kg/m 2 HR: 72 70kV 737 mm/sec 39 ml CA B.S. Harris et al., Radiology 2015
Atherosclerotic Plaque Burden Quantification Prognosis
Prognosis: MUSC Outcomes in 458 Patients Event-Free Survival Probability 1.0 0.8 0.6 0.4 0 Segments with Any Plaque 1-3 Segments with Any Plaque >3 Segments with Any Plaque Patients at risk 0.2 >3 Segments 117 1-3 Segments 179 0 Segments 162 0.0 81 125 119 0 5 10 15 20 25 30 Time [months] 13 37 46 5 23 29 Nance et al. Radiology 2012
Anatomical vs. Functional Testing: PROMISE Anatomical (CCTA) vs Functional exercise electrocardiography nuclear stress testing stress echocardiography For initial evaluation of symptomatic patients with suspected CAD Douglas et al., NEJM 2015
Anatomical vs. Functional Testing: PROMISE Douglas et al., NEJM 2015
Anatomical vs. Functional: SCOT-HEART D. Newby et al., Lancet 2015
Anatomical vs. Functional: SCOT-HEART Ascertain diagnosis and re-classify CAD severity Changes in management more revascularization, more aggressive therapy Reduction of MACE during follow-up, better outcomes D. Newby et al., Lancet 2015
Atherosclerotic Plaque Burden CAD Extent
Lesion-Specific Ischemia with CT Anatomical, structural imaging with any modality cannot determine functional significance of lesions Patient outcomes are improved if only relevant lesions are treated Traditional methods to determine lesionspecific ischemia: Nuc-perfusion, invasive FFR CT-based methods: CT-based perfusion, CT- FFR
Structure / Function: Comprehensive Dx
Dynamic Time Resolved Perfusion ECG-triggered sequential shuttle mode, coverage 12 cm 6 cm 6 cm 6 cm
Structure / Function: Comprehensive Dx MBF: 124ml/100 ml/min MBF: 60ml/100 ml/min
CTA-CTP vs. ICA/SPECT 1.0 0.9 P = 0.166 Sensitivity 0.8 0.7 0.6 0.5 0.4 0.3 0.2 Vessel Based Combined CTA-CTP Combined ICA-SPECT vs. Reference Standard (Revascularization) 0.1 0.0 QCA+SPECT CT F. Rochitte C E et al. Eur Heart J 2013 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1-Specificity
HeartFlow FFR CT Siemens cffr Renker, Schoepf et al., Am J Cardiol 2014
CT-FFR Novel Algorithm for On-Site Evaluation CT-FFR, fluid dynamic modeling Renker et al., Am J Cardiol 2015
CT-FFR Novel Algorithm for On-Site Evaluation CT-FFR, fluid dynamic modeling Baumann et al., Eur Radiol 2015
MACHINE-LEARNING BASED CTA-FFR y logo CFD-based CTA-FFR calculation of synthetic models, and extraction of CT angiographic features that induce trans-coronary pressure gradients CTA-FFR prediction based on angiographic features can be processed on-site in a very short time. Itu et al, J Appl Physiol 2016 (in press)
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CT-FFR: NXT-Trial Prospective multicenter trial n = 254 32 Norgaard et al., JACC 2014
CT-FFR: The PLATFORM Trial Douglas et al. Eur Heart J 2015
Hlatky et al., JACC 2015
Anatomical vs. Functional Testing: PROMISE Douglas et al., NEJM 2015
Stable Angina Pre-Test CAD Risk Low <10% Intermediate 10% - 90% High >90% CCTA <50% Stenosis Non-High Risk CAD High Risk CAD Functional Testing Normal / Moderate Severe CA ± FFR Discharge Optimized Medical Therapy ± Risk Factor Counseling / Modification Optimized Medical Therapy ± Revascularization De Cecco, Schoepf et al., Circulation, 2014
Technology Burgeoning Gentler techniques without losing efficacy Vast reductions in radiation and contrast volume requirements Evidence Accumulating Summary Faster than in most imaging domains Diagnosis / Patient Management Improving
Thank you! schoepf@musc.edu